Aortic Root Aneurysms Surgical Options

At NewYork-Presbyterian/Columbia University Medical Center (NYP/Columbia), we offer a broad spectrum of alternatives for treating aortic root aneurysms. We tailor our approach to the individual needs of each patient. Patients are evaluated with echocardiogram, CT scan, 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 methods. 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 5cm, although we never compromise a patient's safety to achieve a cosmetic result.

Aortic root surgery is performed in this program 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. Done this way, aortic root surgery has been shown to be safe for patients of all ages, including those in their 80s and 90s.

Learn more about axillary cannulation.

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 novel stentless biologic aortic root-valve conduit developed by surgeons in our program. 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.

Valve Sparing Root Replacement (David Procedure)

During Valve Sparing Root Replacement (also called the David Procedure, to give credit to the surgeon who initially conceived the operation, Tirone David, MD), the patient's aortic valve is kept (although it may be repaired and reimplanted) and reconnected to a new section of aortic tissue. By preserving the native aortic valve, patients avoid the need for lifelong anticoagulation therapy (coumadin).

The patient is placed on the heart-lung machine (cardiopulmonary bypass), which takes over the function of the heart and lungs during the operation.

Step 1: The heart is cooled and stopped and a clamp is placed across the aorta. The aorta is transected (divided) just above where the coronary arteries originate. The coronary ostia (openings) are removed as small buttons of tissue. The remainder of the ascending aorta is removed except for the valve tissue.

Step 2: Sutures (stitches) are placed under the valve and passed outside of the aortic annulus (ring of tissue surrounding the valve). A proper vascular graft is selected and attached to the heart with the prepared sutures.

Step 3: The valve is then carefully positioned within the graft to eliminate leaking. A fair bit of customized tailoring is then performed to ensure that the valve leaflets will open and close properly. The valve tissue is completely attached to the graft with a continuous suture technique. Two small holes are created in the graft for reattachment of the coronary arteries.

Step 4: Step 4: Finally, in select cases, the end of the graft is attached to the aortic arch while the brain is carefully protected with a special perfusion technique known as antegrade cerebral perfusion (ACP). (Learn more about ACP)

Columbia Biologic Root Prosthesis

Surgeons at NYP/Columbia have developed a reproducible and durable method of replacing the entire ascending aorta. What began as a simple tailoring of a commercially available valve into a fabric graft has evolved into as novel surgical procedure. Surgeons may now pre-assemble a unique composite biologic graft comprised of a stentless aortic valve and a sinus of Valsalva graft to replicate what is found in nature. Moreover, this conduit will be manufactured to allow surgeons to store the pre-made conduit on the shelf, saving even more time at operation. This graft enhances the reproducibility of aortic root surgery. It also reduces the time that patients must spend on the heart-lung machine, reduces bleeding, and decreases the risk of any subsequent procedure on the valve. 

Video: Columbia 3f Bioroot

The Biologic Root Prosthesis for Replacement of the Aortic Valve and Root

Patients who need aortic root and valve replacement have been able to receive mechanical valves (called the Bentall procedure) since 1960. While mechanical devices have provided a lifesaving option for patients with aortic root aneurysms or valve disease, they have nevertheless been imperfect. Use of mechanical valves requires patients to take anticoagulation medication long-term, which can be problematic for all patients, but especially active patients. Homografts and xenografts (tissues taken from the patient's own body, or from an animal donor, respectively) have been used as well, but these grafts can become severely calcified over time and make reoperation hazardous.

To address the need for a better alternative, surgeons in our program developed a novel stentless biologic aortic root-valve conduit. The conduit contains a new stentless equine pericardial valve and a fabric graft that simulates the ascending aorta (the Gelweave Valsalva graft, marketed by Vascutek). This composite bioroot provides an improved alternative for patients who require an operative procedure on the aortic root.

VIDEO: Preparation Before Surgery

This procedure improves upon previously available forms in several ways. It allows for a larger valve to be used (29mm stentless valve), which significantly improves patients' blood flow compared to other valves. Its prefabrication and increased ease of implantation contribute to shorter operative time, reduced need for cardiopulmonary bypass (use of the heart-lung machine), reduced blood transfusion, and decreased length of stay in the hospital. It works well in patients who require reoperation because of its unique construction. Long term, it is expected that this device will have better durability than available alternatives, because its design distributes stress better than conventional devices, and because the functioning of the valve more closely resembles the native aorta.

The bioprosthesis has been used in hundreds of patients who required aortic root and valve replacement. Results to date indicate that this composite graft is safe and effective in the short term. A study is currently underway to evaluate the longevity of the prosthesis, and also to compare outcomes of this new prosthesis with valve-sparing root replacement.

Homographic Root Replacement

A homograft (human tissue) root replacement follows the same basic steps as the David procedure, except that the aortic valve tissue is also removed. An appropriately sized donor aorta is selected based on the measurement of the aortic annulus (ring of tissue surrounding the valve). Since we are attached to the Morgan Stanley Children's Hospital of NewYork-Presbyterian, we retain a wide range of homograft sizes. The donated valve is then trimmed to size and attached with a continuous suture to the heart. The reattachment of the coronary arteries and the attachment to the aortic arch require continuous sutures as well.

Mechanical Valve Conduit

Modified Bentall with valve conduitThe initial method to repair an aortic aneurysm and valve was described by Hugh Bentall, MD. The procedure has been modified over the years, but the essential points remain. The valve leaflets and aortic aneurysm are completely removed. A mechanical valve conduit (manufactured by either St Jude Medical or ATS Medical) is selected after appropriate sizing has been performed. The valve is sewn into the circle (annulus) remaining after the old valve was removed. The coronary arteries are reimplanted into graft. The graft is then cut to an appropriate length and sewn to the aortic arch. This procedure has been performed for over 40 years and has excellent durability. The downside is that it requires the patient to remain on anticoagulation for the rest of their life.