1) The document discusses various surgical procedures for treating aortic root pathologies. It describes the anatomy of the aortic root and various conditions that can affect it like aneurysms and dissections. 2) Surgical techniques discussed include different types of composite graft replacements, valve sparing procedures, and re-do operations. Specific procedures mentioned are the Bentall procedure and the Ross procedure. 3) Factors that determine whether the aortic valve should be replaced or repaired are discussed. Guidelines for intervention based on aortic root size are also provided.

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Aortic Root Surgery
Dicky A.Wartono ,MD 2019
Aortic Root?
• outflow tract/bridge from the left ventricle,
• supporting structures for the leaflets
• between the LV and the ascending aorta.
• extends from the basal attachments of the
leaflets within the left ventricle to the st
junction
The Aortic Root Consists of :
Aortic annulus
Aortic cusps
Aortic Sinuses
Sinotubular Junction (STJ)

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Too small ( small annulus ) Too large ( Root Aneurysm )
Enlargement
- Nicks ( Post. ) procedure
- Manouguian ( Post.) Procedure
- Konno ( Ant.) Procedure
Replacement
- Bentall Procedure
- Ross Procedure
Replacement + Enlargement
- Ross – Konno
- Modified Ross – Konno
Replacement
Bentall
- Mechanical
- Stented tissue
- Stentless tissue
Valve Sparing
- Remodelling
- Reimplantation

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Root Abscess ( Endocarditis ) Type A Dissection
Replacement
- Bentall
- Mechanical
- Stented tissue
- Stentless tissue
+/-
Mitral / LA
Reconstruction
Bentall
- Mechanical
- Stented tissue
- Stentless tissue
Valve Sparing
- Remodelling
- Reimplantation
Root Aneurysm
• Degenerativež
• Connective Tissue Disorders ž
• Bicuspid Aortopathy
• Post Stenotic
• Chronic Dissections
• 1- Aortic root dilatation secondary to
ascending aortic aneurysm
• 2-Annulo-aortic ectasia and connective tissue
syndromesCTD such as Marfan’s and Ehlers-
Danlos
• 3-Aortic root and ascending aortic dissection
— acute or chronic

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, few data exist on the natural history of iso-
rysms, since they are often associated with
the ascending or descending aorta.
onsidered in patients who have an aortic arch
mal diameter ≥55 mm or who present symp-
compression. Decision-making should weigh
, since aortic arch replacement is associated
mortality and stroke than in surgery of the
ding aorta. Indications for partial or total
nt are more frequently seen in patients who
urgeryon anadjacentaneurysmofthe ascend-
a.
osition (debranching) and TEVAR might be
native to conventional surgery in certain clin-
ally when there is reluctance to expose
mic circulatory arrest; however, especially
transposition, as well as in patients with the
f acute Type B AD, the risk of retrograde
t consequence of the procedure is elevated
d against the remaining risk of conventional
ic aneurysms
descending aortic aneurysms has been
e development of TEVAR using stent grafts.
exist to guide the choice between open
From non-randomized comparisons and
mortality is lower after TEVAR than open
mortality depends on the extent of repair
istics, in particular age and comorbidities.
vival does not differ between TEVAR and
follow-up, there is a contrast between low
rtic complications and relatively high overall
om cardiopulmonary causes.331,332
onsidered in patients who have a descending
iameter ≥55 mm. When surgery is the only
nsidered in patients with a maximal diameter
sholds can be considered in patients with
dications for treatment and the choice
pen surgery should be made by a multidiscip-
rtise in both methods, taking into consider-
comorbidities, and life expectancy, and
h analysis of the arterial tree to assess the
ed risks of each technique: extent and size
d atheroma, collaterals, and size and length
for endovascular grafting and vascular
of information on long-term results of
pt in mind, in particular in young patients.
ay be combined in hybrid approaches.
disease, surgery should be preferred over
dencesupportinganyuseofTEVARinpatients
disease, except in emergency situations in
abilization as a bridge to definitive surgical
Recommendations on interventions on ascending aortic
aneurysms
Recommendations Classa
Levelb
Surgery is indicated in patients who have
aortic root aneurysm, with maximal
aortic diameterc
50 mm for patients
with Marfan syndrome.
I C
Surgery should be considered in patients
who have aortic root aneurysm, with
maximal ascending aortic diameters:
• 45 mm for patients with
Marfan syndrome with risk
factors.d
• 50 mm for patients with
bicuspid valve with risk
factors.e,f
• 55 mm for other patients
with no elastopathy.g,h
Lower thresholds for intervention may
be considered according to body surface
area in patients of small stature or in the
case of rapid progression, aortic valve
regurgitation, planned pregnancy, and
patient’s preference.
Interventions on aortic arch aneurysms
Surgery should be considered in patients
who have isolated aortic arch aneurysm
with maximal diameter 55 mm.
Aortic arch repair may be considered in
patients with aortic arch aneurysm who
already have an indication for surgery of
an adjacent aneurysm located in the
ascending or descending aorta.
IIb C
Interventions on descending aortic aneurysms
TEVAR should be considered, rather than
surgery, when anatomy is suitable.
IIa C
TEVAR should be considered in patients
who have descending aortic aneurysm
with maximal diameter 55 mm.
IIa C
When TEVAR is not technically possible,
surgery should be considered in patients
who have descending aortic aneurysm
with maximal diameter 60 mm.
IIa C
When intervention is indicated, in cases
of Marfan syndrome or other
elastopathies, surgery should be indicated
rather than TEVAR.
IIa C
IIa C
IIb C
IIa C
a
Class of recommendation.
b
Level of evidence.
c
Decision should also take into account the shape of the different parts of the aorta.
Lower thresholds can be used for combining surgery on the ascending aorta for
patients who have an indication for surgery on the aortic valve.
d
Family history of AD and/or aortic size increase .3 mm/year (on repeated
measurements using the same imaging technique, at the same aorta level, with
side-by-side comparison and confirmed by another technique), severe aortic or
mitral regurgitation, or desire for pregnancy.
e
Coarctation of the aorta, systemic hypertension, family history of dissection, or
increase in aortic diameter .3 mm/year (on repeated measurements using the
same imaging technique, measured at the same aorta level, with side-by-side
comparison and confirmed by another technique).
f
Pending comorbidities in the elderly.
g
See text in section 8.
h
For patients with LDS or vascular type IV Ehlers-Danlos syndrome (EDS), lower
thresholds should be considered, possibly even lower than in Marfan syndrome.
Thereare no datato provide figures and a sensible case-by-case approachisthe only
option.
ESC Guidelines
byguestonJuly15,2016http://eurheartj.oxfordjournals.org/Downloadedfrom
2014 ESC Guidelines on the diagnosis and treatment of aortic diseases
30mm = Aneurysm
>55mm = Surgery
>50mm = Bicuspid
>45mm = Marfan
• Gold Standard for young
patients ( < 65y )
• Permanent Anti
coagulation
-Contraindications
-Life style
-Patient preference
• Higher risk for TE
•Most Durable
•Higher risk for infection
( or Re infection)
In 1968, Bentall and De Bono
reported (in a two page case
report), a single patient treated
with a composite graft and
mechanical valve replacement of
the aortic root and ascending aorta
with coronary reimplantation
Sizes 21 mm - 27mm

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• 0.2% Preserved in
glutaraldehyde
•Polyester sewing
cuff
•Alfa amino oleic acid
( anticalcification )
•Zero net pressure
fixation of the leaflets
Improved Hemodynamics
Ideal for Root Abscess
Reduced infection (?)
Low Thromboembolic
Complications
----------------------------------
Availability
Risk of Calcification
( >50% SVD in 20 y )
( immune mediated? )
Homovital ( Fresh)
Cryopreserved
Reimplantation ( David I) Remodelling ( Yacoub)

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When Should We Replace?
• Type A dissection
• Severe AI
• “Broken leaflets”
• Bicuspid Patients
– Significant Thickening
– Prolapse
– Calcification
– Multiple Fenestrations
• Connective Tissue Patients
– Data is unclear
When Should We Repair?
• supple leaflets
• normal annular size
Current options and recommendations for the treatment of thoracic
aortic pathologies involving the aortic arch: an expert consensus
document of the European Association for Cardio-Thoracic surgery
(EACTS) and the European Society for Vascular Surgery (ESVS) 2019

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3
essing
Video 12 . Testing the seating of the prosthesis.
Photo 3 . Commercially available, preclotted composite graft.
Video 13 . Suturing the composite graft into position.
tons
ortic
e left
Stay sutures are placed in the commissures to facili-
tate exposure (Video 11). Valve seating is tested (Vid-
eo 12).
A standard composite graft is selected (MMCTSLink
4, MMCTSLink 5 and MMCTSLink 6) and the valve
implantation is performed using interrupted Ticron
Aortotomy & Periaortic dissection
(Excise aortic valve leaflets)
2
Composite grafts replacement of the aortic roots
Video 2 . Preparing the arch for arterial cannulation.
Video 3 . Arterial cannulation.
Video 4 . Venous cannulation and placing the LV vent.
Video 5 . Crossclamping of the aorta and opening of the aneurysm.
Photo 1 . Aortic root after removal of the aorta of the aortic valve,
with both coronaries detached and mobilised.
Video 7 . Resection of the distal part of aortic aneurysm.
Video 8 . Resection of the proximal portion of the aneurysm and
resection of the valve leaflets.
Video 6 . Antegrade cardioplegia.
Cannulation is performed either in the aortic arch or
– if the disease extends into the arch – the subclavian
artery is cannulated instead (Videos 2, 3).
Standard two-stage arterial cannula (MMCTSLink 3)
and LV vent are used (Video 4).
Surgical procedure
At a moderate hypothermia of 268C the ascending
aorta is cross-clamped (Video 5), heart is arrested
with cardioplegia antegrade cardioplegia (Video 6),
and the cardioplegia is continued in retrograde mode,
and coronaries are continuously perfused with cold
(168C) blood. Aneurysm is totally removed (Photo 1),
(Videos 7, 8 ).
Coronary button Preparation
Composite grafts replacement of the aortic roots
Video 14 . Placement of the sutures in the non-coronary sinus.
Video 15 . Tying the knots.
Video 16 . Cutting the graft to size.
Video 17 . Implantation of the left main coronary artery.
Video 19 . Implantation of the right coronary into the graft.
Video 20 . Implantation of the right coronary into the graft
(continued).
Video 21. Distal anastomosis with the aortic arch.
sutures (MMCTSLink 7) and this surgery can be sup-
ported with Teflon felt or pericardium in friable aortic
roots (Photo 3) (Videos 13, 14, 15). Prefabricated graft
is cut to size to facilitate the implantation of coronary
arteries (Video 16).
The coronary arteries are implanted into the graft
using 4–5 Prolene (MMCTSLink 8) with small needle,
starting with left main coronary artery, which must be
sufficiently mobilised (Videos 17, 18).
Right coronary artery is implanted next (Videos 19,
20); a short clamping of the venous line allows a dil-
atation of the right ventricle to determine the exact
position of the right coronary artery in relation to the
graft. Distal anastomosis is performed either to the
arch or to the remnants of the ascending aorta (Video
21) also using a small needle.
Graft inclusion technique (Schematic 2) is avoided as
Prostetic suture
Composite grafts replacement of the aortic roots
Schematic 2. Details of the graft inclusion technique from Crawford
(Diseases of the Aorta).
Video 22. Finished procedure after decannulation.
Schematic 3 . Running suture line between the cut edge of the aor-
tic wall and the distal portion of the valve sewing ring. The inset
shows a cutaway view from the inside.
Schematic 4 . Separate grafts to both coronary arteries.
Schematic 5 . Detail of the ‘button’-buttress technique used for
anastomosis of the coronary ostia to the graft.
With proper attention to suturing and buttressing the
suture lines with pericardium or Teflon felt, a safe
hemostasis is possible without resorting to the graft
inclusion (Video 22).
Technical innovations
an additional suture after placement of the valve fix-
ation sutures in the annulus.
In case of redo operation, where considerable diffi-
culties can be experienced when mobilizing coronary
arteries, short segments of graft material can be used
to attach coronary arteries to the graft (Schematic 4)
w4x.
The improvement in coronary anastomosis can be
achieved by performing a doubling of tissue at their
coronary orifices as described by Hilgenberg et al. w5x
and Prateli et al. w6x (Schematic 5).
Finally, in difficult redo operations Cabrol technique
has to be utilised, employing a graft which connects
both coronary ostia and is anastomosed to the com-
posite graft itself (Schematic 6).
Results
● The mortality on a procedure, when performed
electively is considered to be low (less than 5%).
Prostetic suture

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Surgical Management of the Aortic Root 135
6.10. Reoperation of the aortic root
Structural failure of the root, pseudoaneurysms, or infection may necessitate redo aortic root
replacement. This is an operation that typically carries a high risk of mortality and
morbidity. Some special considerations when this very difficult operation is undertaken
include: calcified homografts or stentless valves, coronary artery length, and infection.
In patients with a very calcified neo-aortic wall it is often extremely difficult to dissect out
the wall and redo the root as it becomes very adherent to the adjacent structures and
pulmonary artery and coronaries can be injured. Replacing just the aortic valve within the
calcified root is an option. With the advent of trans aortic valve implantation (TAVI), this
may be an excellent option in high risk patients. El-Hamamsy et al compared the Freestyle
graft with homograft aortic root replacement in a prospective, randomized trial.[139] One-
hundred sixty-six patients with an average age of 65 years had a mean follow-up of 7.6
years. Significant conclusions were made from this data including an improved age of
survival (80 vs. 77 years), lower rate of reoperation (100% vs. 90%), and
echocardiographically patients had less signs of valvular deterioration (86% vs. 30%) in the
FreeStyle group.
Figure 14. Aortic root replacement via the Cabrol technique. Coronary buttons are sutured side-to-side
to a Dacron interposition graft during root replacement.[140]
5
c roots
arate grafts to both coronary arteries.
ail of the ‘button’-buttress technique used for
e coronary ostia to the graft.
uture after placement of the valve fix-
n the annulus.
o operation, where considerable diffi-
experienced when mobilizing coronary
segments of graft material can be used
nary arteries to the graft (Schematic 4)
ent in coronary anastomosis can be
erforming a doubling of tissue at their
es as described by Hilgenberg et al. w5x
al. w6x (Schematic 5).
cult redo operations Cabrol technique
ed, employing a graft which connects
ostia and is anastomosed to the com-
elf (Schematic 6).
y on a procedure, when performed
considered to be low (less than 5%).
ncreased in all the patients with con-
ue disorders (Marfan) and in patients
der emergency conditions.
ure also carries considerable risk when
acute Type A dissection.
5
Composite grafts replacement of the aortic roots
Schematic 2. Details of the graft inclusion technique from Crawford
(Diseases of the Aorta).
Video 22. Finished procedure after decannulation.
Schematic 3 . Running suture line between the cut edge of the aor-
tic wall and the distal portion of the valve sewing ring. The inset
shows a cutaway view from the inside.
Schematic 4 . Separate grafts to both coronary arteries.
Schematic 5 . Detail of the ‘button’-buttress technique used for
anastomosis of the coronary ostia to the graft.
With proper attention to suturing and buttressing the
suture lines with pericardium or Teflon felt, a safe
hemostasis is possible without resorting to the graft
inclusion (Video 22).
Technical innovations
Several modifications of the technique have been pro-
posed in order to eliminate the risk of bleeding (Sche-
matic 3).
This particular modification by Copeland et al. w3x
improves the hemostasis at the aortic root by running
an additional suture after placement of the valve fix-
ation sutures in the annulus.
In case of redo operation, where considerable diffi-
culties can be experienced when mobilizing coronary
arteries, short segments of graft material can be used
to attach coronary arteries to the graft (Schematic 4)
w4x.
The improvement in coronary anastomosis can be
achieved by performing a doubling of tissue at their
coronary orifices as described by Hilgenberg et al. w5x
and Prateli et al. w6x (Schematic 5).
Finally, in difficult redo operations Cabrol technique
has to be utilised, employing a graft which connects
both coronary ostia and is anastomosed to the com-
posite graft itself (Schematic 6).
Results
● The mortality on a procedure, when performed
electively is considered to be low (less than 5%).
● The risk is increased in all the patients with con-
nective tissue disorders (Marfan) and in patients
operated under emergency conditions.
● This procedure also carries considerable risk when
performed in acute Type A dissection.
Implantation of the Left coronary into the graft

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• Conclusions
• Aortic Root surgery using Composute Valve graft,
is a safe with reasonable outcome
• Timing of Surgery, & placement of coronary
button is one of the most contributing factor
• There are few option for managing fragile tissue
• Distal…………