Valve-Sparing Aortic Root Replacement, Including Modified David Reimplantation Surgery

What is valve-sparing aortic root replacement?

Valve-sparing aortic root replacement is a surgery that replaces the part of your aorta that’s directly attached to your heart (aortic root) while keeping your natural (native) aortic valve. Your aortic root connects with your heart at your left ventricle, which is your heart’s main pumping chamber. Your aortic root contains your aortic valve. Your aortic valve is the “door” that manages blood flow from your left ventricle to your aorta.

Your heart pumps blood through your aortic valve with each heartbeat. When your heart contracts (systole), the leaflets (flaps) of your aortic valve open to let blood flow into your aorta. The flaps then close to keep blood from flowing backward into your heart when your heart relaxes (diastole).

Some people have a damaged aortic root but healthy, or only mildly diseased, valve flaps. In that case, there’s no need for a new aortic valve. All you need is a new aortic root and potentially sparing or preservation of your valve flaps. But in the traditional aortic root replacement surgery (composite graft replacement, also known as the Bentall procedure), a surgeon replaces both your aortic root and your aortic valve.

Valve-sparing aortic root replacement offers an alternative to the Bentall procedure. It replaces your aortic root but allows you to keep your natural aortic valve. Keeping your aortic valve, rather than receiving a new valve, is a better option for many people. It avoids many of the risks associated with valve replacement and generally has excellent outcomes, especially at high-volume surgical centers with experienced surgeons who do many of these operations. Also, with valve replacement with a mechanical valve, you’ll need to be on the blood thinner Coumadin for the rest of your life.

What does this surgery treat?

Valve-sparing aortic root replacement treats:

• Aortic root aneurysm. This is an abnormal dilatation (widening) of your aortic root. If this part of your aorta grows too wide, it can prevent your valve from fully closing or result in your aorta tearing (aortic dissection) or bursting like a blown-up balloon. The enlarged root interferes with normal valve function and can cause a leaky valve (aortic regurgitation).
• Ascending aortic aneurysm with dilated aortic sinuses. This means there’s an abnormal dilatation of a portion of your ascending aorta. Plus, your aortic sinuses (three segments of your aortic root that naturally bulge outward a bit) are wider than normal, but not quite at the threshold for an aneurysm.

The wider any portion of your aorta grows, the greater your risk for complications like an aneurysm rupture or dissection. People with certain inherited connective tissue disorders, such as Marfan syndrome, face a higher risk of aortic root aneurysms and associated complications.

So, surgeons weigh the risks of surgery with the risks of complications in deciding if and when a person needs surgery. Surgeons evaluate each person individually to see if valve-sparing aortic root replacement, as opposed to the Bentall procedure, is right for them.

Valve-sparing aortic root replacement has excellent short- and long-term outcomes in properly chosen candidates. You may be a candidate for this surgery if your aortic valve:

• Has minimal or no calcium build-up (calcification).
• Has minimal or no damage.
• Works properly or is repairable.

What are the techniques for valve-sparing aortic root replacement?

There are two main techniques surgeons use to replace your aortic root while keeping your aortic valve:

• Reimplantation of your aortic valve, or the newer, more durable modified reimplantation operation.
• Remodeling your aortic root.

This article covers modified reimplantation surgery. Surgeons typically choose reimplantation surgery for people who:

• Are under age 75.
• Have a connective tissue disorder.
• Have an aortic root aneurysm that’s linked to an inherited disorder.

Surgeons have modified the reimplantation technique to improve its durable long-term outcomes. These modifications are discussed later under procedure details.

How should I prepare for surgery?

Your surgeon will give you detailed instructions as you prepare for your surgery. It’s important to follow them closely. In general, you may need to:

• Make changes to your usual medication schedule (don’t stop taking any medications or make any changes unless your surgeon tells you to).
• Fast after midnight the night before your surgery. This means no foods or liquids, including water.
• Take certain medications the morning of your surgery.
• Arrange for someone to drive you to the hospital on the day of your surgery and pick you up on the day you go home.

Your surgeon will order tests to help plan the details of your surgery. These may include:

• Echocardiogram.
• Blood tests.
• Cardiac and chest EKG gated CT scan.
• Heart MRI.
• Coronary angiogram.
• Genetic blood test for suspected connective tissue disorder.

You’ll also talk with your surgeon about:

• Any medications you’re taking, including those that are over the counter.
• Medical conditions you have.
• Your general state of health, such as whether you’ve recently been sick.
• Smoking or tobacco use. You should avoid all tobacco products for at least one month before your surgery.
• Details and risks of your surgery, and long-term prognosis and durability of the valve.

During your appointments, don’t hesitate to ask any questions that come up. It’s important that you fully understand what you need to do and what you can expect.

What happens during surgery?

Valve-sparing aortic root replacement usually takes four to six hours, and your heart is usually stopped for an hour by an experienced surgeon. To perform a valve-sparing aortic root replacement, your surgical care team will perform the following steps. (There are modifications to this procedure that you can read about in the next section.)

1. Give you anesthesia. Anesthesia is medication that puts you to sleep so you won’t be awake or feel pain during the surgery.
2. Make an incision in your chest. Your surgeon performs a median sternotomy to gain access to your heart.
3. Connect you to a heart-lung bypass machine.Surgeons also call this going “on the pump.” A cardiopulmonary bypass (heart-lung) machine does the work of your heart and lungs during the surgery. Your care team may also use this machine to give you medication, called cardioplegia solution, to temporarily stop your heart from beating and protect your heart during the surgery.
4. Mobilize your valve. Your surgeon separates your aortic valve from the tissues surrounding it.
5. Repair valve flaps.If needed, your surgeon repairs damage to the valve flaps. This is sometimes necessary if you have a bicuspid aortic valve or a very leaky valve.
6. Remove the damaged portions of your aorta. Your surgeon cuts away the abnormally widened portions of your aortic root and, if relevant, your ascending aorta.
7. Insert a graft.This graft is a collagen-coated polyester (fabric) tube that replaces the damaged portion of your aorta. Your surgeon chooses the proper-sized graft for you. They use stitches to sew the graft into place.
8. Reimplant your valve.Your surgeon implants your valve into the graft and sews it into place.
9. Test your valve. Your surgeon sends a solution through the graft to make sure your valve works properly. They also check the valve flaps to make sure they’re the correct shape and open and close as they should.
10. Finalize the procedure. Your surgeon completes necessary final steps, such as connecting your coronary arteries to the graft. They also connect the distal end of your graft (the end that’s farther from your heart) to the remaining portion of your ascending aorta or aortic arch.
11. Take you off the pump. Your team weans you from cardiopulmonary bypass so blood can begin flowing through your heart and lungs again. Your surgeon closes the incision in your chest.
12. Perform an echocardiogram. Your team checks the success of the surgery with a transesophageal echocardiogram before leaving the operating room.

Procedure modifications

Over the years, surgeons have made changes to the standard reimplantation surgery to improve its outcomes. For example, Dr. Lars Svensson’s modifications include the following:

• Reduce the diameter of your aortic annulus based on your body surface area. The annulus is the fibrous, crown-shaped base that supports your aortic valve. If the annulus is too wide, your valve may leak. To lower the risk of this problem, your surgeon calculates the ideal diameter of the annulus based on your body surface area. During your surgery, they use a tool called a Hegar’s dilator to make the base of your graft the appropriate size.
• Create new aortic sinuses (neosinuses).Using the Hegar’s dilator to size your graft also allows for the creation of new aortic sinuses (slight, necessary widening in three areas of your aortic root). These new sinuses form when your surgeon crimps the graft to fit the size of the dilator. This solves a drawback of a traditional fabric graft: It’s a straight tube that doesn’t contain sinuses. Creating new sinuses allows for more natural blood flow through your valve and avoids unnecessary wear and tear on your valve flaps against your graft. Neosinuses also lower your risk of developing a leaky valve over time.

You can talk to your surgeon to learn more about the specific techniques they may use.

What happens after the surgery is done?

You can expect to spend a day or two in the intensive care unit (ICU) before moving to a regular hospital room. Most people go home in about four days to one week. Before you leave, you’ll have a repeat echocardiogram and chest CT scan to check that all is well with your repair. You can think of this as your “graduation picture.”

While you’re in the hospital, your care team will closely monitor you to make sure you’re recovering as you should. You’ll be hooked up to tubes to drain fluids, and you’ll receive medications to ease your pain and prevent blood clots.

It’s essential to follow your care team’s instructions and take things slow. Pushing yourself too hard, too fast can set back your recovery.

You won’t be able to drive until your provider says it’s safe. So, make sure to arrange for someone to drive you home when you’re discharged.

What are the benefits of this surgery?

Valve-sparing aortic root replacement (reimplantation) has several benefits over the Bentall procedure, including:

• Lower risk of needing another aortic valve operation down the road.
• No need for lifelong anticoagulation (blood thinners).
• Lower risk of blood clots, bleeding, stroke and endocarditis (infection of your valve).
• Lower risk of developing a leaky aortic valve.

How successful is this surgery?

This surgery has excellent short- and long-term outcomes, particularly when performed at high-volume centers by experienced surgeons. Research shows:

• The surgery successfully repairs the aortic root and valve in over 95% of cases.
• The number of people who survive the operation is above 99%.
• Depending on the condition of your valve, you likely won’t need another aortic valve surgery. Most people (about 92% to 98%) don’t need it in the 10 years following surgery.
• Among people with tricuspid aortic valve anatomy or a connective tissue disorder, about 95% don’t need another aortic valve surgery and don’t have severe aortic valve regurgitation 10 years later.

What are the risks or complications?

Valve-sparing aortic root replacement is a major surgery and requires a skilled and experienced surgeon. Like other major surgeries, it carries risks and complications, but these are uncommon. These include:

• Bleeding.
• Blood clots.
• Breathing problems.
• Heart attack or stroke.
• Infection in the graft.
• Infection in your lungs, urinary tract or belly.
• Kidney failure.
• Needing a pacemaker.

It’s important to talk to your surgeon about your individual level of risk based on your overall health and underlying medical conditions. In experienced surgical hands, risks are minimal.

What is the recovery time?

Full recovery usually takes six weeks. Participating in cardiac rehab can support your recovery and help you get back on your feet again sooner. It can also help to meet other people who are going through the same experiences as you.

During and after your recovery, you’ll meet your surgery team for follow-up appointments. They’ll tell you how often you need to come in.

After you feel better, it can be easy to think follow-ups aren’t necessary. But they are. Your care team, including your cardiologist, will monitor you long-term through routine imaging tests to make sure your heart and blood vessels are healthy. So, be sure to go to all of your appointments and be an active partner in your care.

When can I go back to my usual routine?

Your surgeon will tell you when you can return to your usual activities. Most people have to wait at least six weeks to:

• Drive.
• Lift heavy objects.
• Return to work.

However, many people have returned to professional sports after a modified reimplantation, such as NBA players.

When should I call my healthcare provider?

Call your provider immediately if you experience signs of a complication after your surgery, including:

• Redness, pain, warmth or swelling around your incision.
• Blood or clear fluid soaking through your bandage.
• Green or yellow drainage from your incision.
• Edges of your incision coming apart.
• Chest pain.
• Shortness of breath.
• Swollen legs or inability to move your legs.
• Dizziness, fainting or extreme fatigue.
• Coughing up blood, or coughing up yellow or green mucus.
• Chills or fever.
• Blood in your poop.

A note from Cleveland Clinic

Valve-sparing aortic root replacement can help protect your heart and health for many years to come. Seeking care at an experienced hospital that routinely performs these surgeries gives you the best chance of a successful outcome.

It’s normal to feel scared or nervous going into any major surgery. Your surgeon will understand this, and they’ll help you feel comfortable with the process. Don’t hesitate to ask any and all questions that come to mind. This is the time to get all the information you need and make sure you understand what will happen before, during and after your surgery.

It’s also important to tell your family and friends about your surgery and ask for their help. Having a community of support around you as you recover can make a huge difference as you get back to your normal routine.