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      Combined Replacement of Aortic Valve and Ascending Aorta—A 70-Year Evolution of Surgical Techniques

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          Abstract

          Simultaneous replacement of the ascending aorta and aortic valve has always been a challenging procedure. Introduction of composite conduits, through various ingenious procedures and their modifications, has changed the outlook of patients with aortic valve disease and ascending aorta pathology. In the past 70 years, progress of surgical techniques and prosthetic materials has allowed such patients to undergo radical procedures providing excellent early and long-term results in both young and elderly patients. This article aims to review the most important technical advances in the treatment of aortic valve disease and ascending aorta aneurysms recognizing the important contributions in this field.

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          Most cited references 41

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          A technique for complete replacement of the ascending aorta.

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            Comparison of the structure of the aortic valve and ascending aorta in adults having aortic valve replacement for aortic stenosis versus for pure aortic regurgitation and resection of the ascending aorta for aneurysm.

            There is debate concerning whether an aneurysmal ascending aorta should be replaced when associated with a dysfunctioning aortic valve that is to be replaced. To examine this issue, we divided the patients by type of aortic valve dysfunction-either aortic stenosis (AS) or pure aortic regurgitation (AR)-something not previously undertaken. Of 122 patients with ascending aortic aneurysm (unassociated with aortitis or acute dissection), the aortic valve was congenitally malformed (unicuspid or bicuspid) in 58 (98%) of the 59 AS patients, and in 38 (60%) of the 63 pure AR patients. Ascending aortic medial elastic fiber loss (EFL) (graded 0 to 4+) was zero or 1+ in 53 (90%) of the AS patients, in 20 (53%) of the 38 AR patients with bicuspid valves, and in all 12 AR patients with tricuspid valves unassociated with the Marfan syndrome. An unadjusted analysis showed that, among the 96 patients with congenitally malformed valves, the 38 AR patients had a significantly higher likelihood of 2+ to 4+ EFL than the 58 AS patients (crude odds ratio: 8.78; 95% confidence interval: 2.95, 28.13). These data strongly suggest that the type of aortic valve dysfunction-AS versus pure AR-is very helpful in predicting loss of aortic medial elastic fibers in patients with ascending aortic aneurysms and aortic valve disease.
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              Complete replacement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach.

              Thirty patients had total replacement of the ascending aorta with reimplantation of the coronary arteries, 20 for a fusiform aneurysm of the ascending aorta and 10 because of a dissection of the ascending aorta, of which there were acute. All had associated aortic insufficiency. The technique consists of implantation, within the aneurysmal sac, of a Dacron prosthesis containing a Björk-Shiley aortic valve. The coronary orifices are anastomosed to the tubular Dacron prosthesis by means of a second smaller Dacron tube. The aneurysmal pouch is then closed over the entire appliance and a fistula between the aneurysmal sac and the right atrial appendage is created to drain oozing from the prosthesis. The operative mortality was 10% (three deaths) and the late mortality has been 14.8% (four deaths). The deaths, early and late, have been confined to the first 10 cases, during which time the technique was being developed. There has been no mortality among the last 20 patients. The 23 survivors followed for an average of 19 1/2 months (range 6 months to 5 1/2 years) are in NYHA Functional Class I (21) or II (two). The technical modifications utilized in this series have simplified the operation and permit the proposal of this technique for aneurysm involving the entire ascending aorta.
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                Author and article information

                Journal
                Aorta (Stamford)
                Aorta (Stamford)
                10.1055/s-00039245
                AORTA Journal
                Thieme Medical Publishers, Inc. (333 Seventh Avenue, 18th Floor, New York, NY 10001, USA )
                2325-4637
                June 2021
                11 October 2021
                1 October 2021
                : 9
                : 3
                : 118-123
                Affiliations
                [1 ]Division of Cardiac Surgery, Cardiothoracic Department, University Hospital, Udine, Italy
                Author notes
                Address for correspondence Uberto Bortolotti, MD Largo Traiano 23, 35036 Montegrotto Terme (PD)Italy uberto48@ 123456gmail.com
                Article
                200034
                10.1055/s-0041-1729913
                8598315
                34634836
                1cc9e415-285e-413d-8880-0af446f16cab
                The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ )

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Funding
                Funding None.
                Categories
                Historical Perspective

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