Reply to Kestelli et al.

Abstract

We appreciate the interest expressed by Kestelli et al. [1] in our report on aortic root enlargement (ARE). The main objective of our work was to present the perioperative and short-term mortality and morbidity experience of ARE. For this purpose, we used a control group of patients with small aortic roots (SARs) in whom a 21 mm aortic prosthesis, or smaller, was implanted. Our elderly population, especially women, are of small stature and, for that reason, we were dealing mostly with SARs in both groups (mean prosthesis labelled-size: ARE, 21.88 ± 1.03; SAR, 20.7 ± 0.46). As acknowledged in the manuscript, one of the shortcomings of the study was our incapacity to evaluate the long-term impact of ARE, which others have regarded as non-important. As correctly pointed out by Kerstelli, preoperative values of left ventricular (LV) posterior wall thickness and interventricular septum (IVS) were lacking in the SAR group and there were no statistically significant differences between both groups. Regarding the ‘lack’ of comparison of ejection fraction, Table 1 of the manuscript clearly shows that LV dysfunction was not different between the groups (P = 0.121). We agree that associated procedures would affect the mortality rate and although there were no statistical differences in combined coronary artery bypass grafting and tricuspid repair (P > 0.05), this was not the case with mitral valve surgery (P 15 mm). Nevertheless, more important than the ‘value’ itself is the appearance of a bulged septum in the outflow tract that we took into account. Others have recently demonstrated its importance [4]. In our experience, adding a myectomy does not increase the operative risk and we did not encounter any surgical complications, such as iatrogenic ventricular septal defect. Therefore, we share the opinion that a concomitant myectomy should be considered for patients with septal hypertrophy, even when dynamic obstruction is not demonstrated [5]. We practice it almost routinely. As an alternative, Kestelli et al. suggest stentless valves or the ST Jude HP for their superior haemodynamic instead of ARE. We think that there are ‘many ways to skin a cat’ and ARE is a valid option, because it also provided low gradients and probably carried a lower mortality than some valve substitutes with allegedly better haemodynamic profiles (stentless valves, homografts and Ross procedure). Besides, it can be used with any type of prosthesis.