Thanks for the link, Derek. I just went through several of these, and found them very interesting. Tirone David does argue for replacing the entire root with a graft modeled to include artificial sinuses, but he also says in the presentation that this is brand new and not available in the US. I think this is Dr. David, of the David procedure, which is a valve sparing aortic root replacement. He is well known for the procedure which allows people with otherwise fine tricuspid valves to retain their own valve by reimplanting it in an artificial graft.
In Dr. Sundt's presentation, he has a picture of the root dilating after graft of the aorta and valve replacement, but mentions that this occurs frequently in Marfan's syndrome patients but not to our knowledge in BAV patients. I tried to find another presentation with this picture, as he seemed to reference that he had lifted it from another esteemed colleague who was presenting at the symposium, but couldn't find it. I'm not sure that Dr. Sundt came to any conclusions, but to me he was saying that with Marfan's syndrome you would want to replace the root, but he wasn't so sure with straight BAV.
There was a presentation in the abstracts (Abstract 86) that discussed the fate of remaining sinus of valsalva after followup on on several patients. I may be incorrect and someone can feel free to jump in, but I believe the sinus of valsalva is the aortic root? If that is the case, the conclusions of the paper, a 17 year follow-up, were the following:
The sinuses of Valsalva rarely dilate significantly after AVR and aortic repair
Separate valve and graft remains a reasonable option in the absence of significant root dilatation
The ascending aorta remains at risk of late dilatation if treated with aortoplasty
I will post a separate thread about my visit with the surgeon and the cardiologist, but in general three different docs told me today that I should not worry about further dilation of the root. In my particular case, the root is 3.9-4.0cm (4.2 was measured on echo, CT says 3.9cm) which for my body surface is darn near normal per the cardio. I am a fairly large guy, so that is the basis of their statement. With the reduced pressure gradient, the more-laminar flow, and the replaced aorta, they seem to be banking on the fact that the dilation will not go further. They said the risk of coronary artery blockage from scar tissue and the increased surgery time on bypass was higher than the risk of dilation (which is very low according to them), and I am hoping they are right.
I certainly have the concerns in the back of my head about having further surgery down the road for root dilation, and part of me now thinks it would be nice if I had had complete replacement. However, it is over and done with for me, so all I can do is tell you what my surgeon and cardio said. Grey, I would take this information and ask a lot more questions (and pointed questions) of your surgeon, and maybe even call for a consult with Mayo, Cleveland, Mass, etc. See what others would say about your particular case. It was good for me in retrospect to see the conclusions of the study presented at the Aortic Symposium and hear the confidence in my cardio and surgeon, but given the fact that you haven't had the surgery yet I would definitely pursue it further. It may be that your particular surgeon doesn't have a lot of experience with replacing the root, and that may be driving their decision (or my surgeon's decision, for that matter) to not do a full replacement. Let me know what you find out.
