Aortic root surgery; …sparing the valve

We read with great interest the study by Beckmann et al. [1] entitled ‘Aortic valve-sparing root replacement in patients with bicuspid aortic valve: long-term outcome with the David I procedure over 20 years’. We would like to congratulate them on their excellent surgical results and their well-documented article. The benefits of preserving the aortic valve, tricuspid or bicuspid, is well known in the international literature. The risk of reoperation has to be weighed against the risks and benefits of prosthetic graft replacement [2]. Mechanical valve prostheses have the disadvantage of life-long anticoagulation with associated risks of bleeding and thromboembolism [1, 2]. The rate of bleeding after mechanical valve implantation is reported to be 16% in 10 years and 61% in 20 years [2]. Thromboembolic complications occur in 10% of patients after 10 years and 24% after 20 years [2]. With these data in mind, we have to repair any pliable aortic valve, tricuspid or bicuspid. There are well-described techniques with good mid- and long-term results [3, 4]. We would like to comment on two issues of the article by Beckmann et al. The graft used in all patients of the above-mentioned series was straight; we believe that the graft should mimic the sinus of Valsalva to have normal blood flow through the valve and the ‘synthetic’ aortic root. The grafts mimicking the sinus provide a more physiological and less turbulent flow that could destroy the repaired valve. Then, they did not use the caliper of Schäfers that aims to perform a standardized repair of the aortic valve, either tricuspid or bicuspid [5, 6]. The mid- and long-term results are better after the introduction of this tool [4, 5]. We consider it extremely useful to measure the coaptation area of the cusps. Of course the results in patients with Marfan syndrome or other connective tissue diseases, in patients with acute aortic dissection, could not be as good as in patients with simple dilatation of the root and regurgitation of the valve. In conclusion, we would like to suggest the use of grafts mimicking the sinus of Valsalva and the caliper of Schäfers for better long-term results in aortic root surgery and repair of the bicuspid valve. Then, if the cusps are pliable, the aortic valve, either tricuspid or tricuspid, has to be repaired.