The evolution of aortic root surgery for Marfan syndrome

Abstract

In the development of a complex process with multiple iterations, a point may be reached when the next best step is simplification. The pre-emptive management of the Marfan aortic root, which has the single goal of preventing fatal dissection, may be an example. In the light of our report in Interactive CardioVascular and Thoracic Surgery w1x is it time to ask if, with progress in imaging and computer aided design, we might be approaching a point where simplification is the next best step in the elective management of the aortic root in the early uncomplicated Marfan patient? Pepper et al. report the technical realisation of a concept of individualised external aortic root support (EARS) w1x which was proposed and developed by the design engineer Golesworthy w2x. He inherited and has expressed the Marfan gene with all of its characteristic manifestations including dilatation of his aortic root. While undergoing regular echo measurements to see if the aortic root was enlarging, to the point where he met existing criteria for a root replacement, he instigated a radical rethink on our surgical approach. While aware of the work of the surgeon Robicsek and the engineer Thubrikar w3x, Golesworthy postulated that surgeons had thus far failed to take advantage of the techniques of computer aided design. He proposed that we use the very high-resolution spatial data made available by modern imaging to make an exact, customised support for the Marfan aortic root. The anatomical requirements were explored in collaboration with Treasure et al. w4x and Golesworthy himself was the recipient of the first implant w2x. The Bentall operation can be performed at low risk in expert hands and valve-sparing versions, with all their advantages, are now available w5, 6x. During training in the 1970s the situation was very different. The Bentall operation had not long been described w7x and aortic root surgery was a technical challenge, not to be undertaken unless the clinical indications were compelling – but for Marfan patients the very high risk of fatal dissection at young age constituted a compelling argument. For a young surgeon in