One ring to rule them all

Abstract

When valve-sparing root replacement was introduced, it soon became an attractive option for children and adolescents presenting with aortic root aneurysm due to disorders of connective tissue. In this young patient population, a Bentall procedure with a mechanical valve and life-long anticoagulation seemed a particularly uninviting option. At that time, many surgeons chose to perform a remodelling procedure as it was thought to be simpler in execution. While the initial results were very promising, patients soon started to come back with aortic valve regurgitation (AR) due to annular dilatation. This prompted many surgeons to adopt the reimplantation technique as the method of choice for young patients with disorders of connective tissue. In the current edition of the Journal, Chauvette et al. [1] report results from the AVIATOR registry that encompasses a large number of patients who underwent valve-sparing root replacement using different techniques. This article conveys several important messages: (i) Valve-sparing root replacement is safe. There was only 1 perioperative death resulting in a 0.4% mortality. (ii) Supporting the aortic anulus is key. As long as the aortic anulus is supported, it does not matter whether a reimplantation or a remodelling technique is performed. (iii) Valve-sparing root replacement in young patients with disorders of connective tissue is a durable procedure—but not as durable as we had hoped for. The authors report 22% of AR ≥2 after 10 years. While this is in line with previously reported results in patients with Marfan syndrome, it is underwhelming to note that the median time to develop AR ≥2 was <3 years. Given the vast experience of participating centres that have contributed to this study, mistakes in strategy and surgical technique seem unlikely to explain this rather high incidence of aortic valve regurgitation after such a short period of time. This raises the important question how we can identify those patients who will develop aortic regurgitation over time? Is it just bad luck or are there anatomical factors that predispose patients for failing valve-sparing root replacements that we have not yet identified?