HCA Healthcare at Mercy Hospital offers a broad spectrum of emergent and elective alternatives for treating aortic aneurysms and dissections. We tailor our approach to the individual needs of each patient, by employing a multidisciplinary team in our center. Patients are evaluated with echocardiogram, CT scan or MRI, and cardiac catheterization, when required. Based on those findings, we engage in a detailed discussion with the patient and family about appropriate surgical options.
During aortic root operations, the aortic valve may be repaired or replaced, depending on its appearance. Many aortic aneurysm surgeries can be performed with minimally invasive approaches. Compared to traditional surgery, minimally invasive approaches may be associated with reduced pain, less scarring, and shorter recovery time. Most aneurysms of the aortic root can be done through skin incisions of approximately 3inches, although we never compromise a patient’s safety to achieve a cosmetic result.
More complex surgeries involving the arch may be performed using axillary cannulation. This method enables the surgeons to preserve the natural flow of blood through the body and to the brain by redirecting blood from the aorta through an artery under the clavicle. This method of axillary cannulation has been shown to be safer than other methods of maintaining blood flow. By combining innovative methods of exposure and advanced methods of perfusion, aortic root surgery has been shown to be safe for patients of all ages, including those in their 80s and 90s.
Options in Aortic Aneurysm Surgery
Valve-Sparing Root Replacement (David Procedure): Removal of the damaged section of aorta, while preserving the aortic valve. Since the aortic valve remains intact, anticoagulation therapy (to prevent blood clots) is not required.
Biologic Prothesis and graft: Replacement of the aortic root and valve with a biologic aortic root-valve conduit. This option provides patients with important advantages over the other available options.
Homograft root replacement: Removal of the aorta and the aortic valve, as well as the attachment of the coronary arteries. The aortic root is then reconstructed with the aid of a cadaveric human (homograft) aorta. The use of a human replacement valve eliminates the need for anticoagulation, provides superior blood circulation (hemodynamic function), and may offer longer freedom from reoperation than animal tissue alternatives.
Ross Procedure: The aortic root is removed, including the valve. The coronary arteries are removed from the diseased aorta. The pulmonary artery including the valve is removed. This pulmonary artery conduit will then become the new aorta. A cadaveric conduit is then selected to replace the pulmonary artery. The Ross procedure is generally reserved for younger patients, as valve-sparing procedures and advanced biological conduits have largely supplanted its use in adults.
Mechanical valve conduit: Replacement of the entire aorta root and aortic valve with a combination of a mechanical valve with an attached tube graft. Also called the modified Bentall operation, this approach is often used in younger patients or in those patients who wish to avoid reoperation. Anticoagulation therapy is required.
Traditionally, patients with leaky aortic valves – known as aortic regurgitation – have had no choice other than valve replacement with mechanical, animal, or human homograft valves. However, techniques have been developed to repair these aortic valves, avoiding the need for blood thinners or early reoperation. One such procedure is known as the David procedure, in which the aortic valve and root are reconstructed and reshaped. Our team has a long and robust experience with the David procedure, and offer this as a routine treatment of aortic regurgitation in appropriate patients.
The Ross Procedure is a surgical option for children and young adults with diseased aortic valves or aortic valve failure. In this advanced aortic valve operation, a diseased aortic valve (which is either leaking or stenotic) is removed and the patient’s own pulmonary valve is substituted in its place. MCVI is proud to offer this option, and our surgeons have a long and reproducible experience with this complex procedure. complex operation. Using a patient’s own valve tissue, the Ross procedure eliminates the need for a replacement for as many as 20 years, and also eliminates the need for blood thinners. This is especially well suited for children and adolescents for whom artificial valve options are limited.
Aortic Valve Repair or Replacement?
The decision whether to repair or replace the aortic valve begins during the first office consultation. The first appointment often leads to the surgeon listening to the patient’s chest and examination by echocardiography. The surgeon views the results together with the patient, at which time the possibility of repair is discussed.
Factors that affect the decision include:
- the presence of significant calcium on the valve;
- the presence of connective tissue disorders with more than one leaflet prolapsing;
- significant fenestration of the valve; or
- progressive leaflet deterioration.
At the time of surgery, transesophageal echocardiography (TEE) provides good three-dimensional imaging of the valve and helps to guide the surgeon. Once the aorta is visible, then final decision can be made to either repair or replace the aortic valve. The most important determinant is whether a repaired valve will last longer than a prosthetic.
In assessing the valve, the surgeon looks at its appearance. We ask several questions to make an informed, evidence-based decision. Is there a broken leaflet? Is it normal in appearance, or not? Is it bicuspid (abnormal) or tricuspid (normal)? If it is bicuspid, is the orifice large enough to repair any stenosis? Is the valve leaking at all? Extensive repair to achieve normal functioning may not be in the patient’s best interest, but if the defect is correctable, then it is always considered.