What conditions must be fulfilled to preserve the aortic valve in type A aortic dissection surgery?

Conditions for Aortic Valve Preservation in Type A Aortic Dissection Surgery

Preserve the aortic valve with a tubular graft when the aortic root is normal-sized AND the valve cusps show no pathological changes AND there is no commissural detachment. 1

Critical Pre-Operative Assessment

Before deciding on valve preservation, two key questions must be answered 1:

1. Aortic Root Size Assessment

• Normal aortic root diameter (not ectatic) 1
• No downstream displacement of coronary ostia 1
• If the root is ectatic (enlarged), composite graft replacement is required instead 1

2. Aortic Valve Condition Assessment

The valve cusps must meet ALL of the following criteria 1:

• No commissural detachment of the aortic valve leaflets 1
• No acute pathological changes of the leaflets 1
• No chronic pathological changes of the leaflets 1
• No congenital abnormalities (though bicuspid valve repair has been reported in select cases) 1
• No acquired abnormalities of the valve 1

Degree of Aortic Regurgitation Considerations

Absent or mild aortic regurgitation is the ideal scenario for valve preservation 2:

• Patients with no or mild aortic insufficiency have excellent long-term outcomes with valve preservation (93% freedom from reoperation at 5 years, 80% at 10 years) 2
• Patients with moderate-to-severe aortic regurgitation have significantly worse outcomes (81% freedom from reoperation at 5 years, only 40% at 10 years) and represent an increased risk for recurrent valvular insufficiency 2
• Aortic valve annulus diameter ≤27 mm is critical—annulus >27 mm is an independent risk factor for reoperation (RR = 4.2) and requires more extensive root procedures 3

Technical Feasibility Requirements

Additional anatomical considerations that must be met 1:

• Dissection has not disrupted the coronary vessels at the ostia 1
• Valve cusps and their insertion lines remain intact 1
• If commissures are detached but otherwise meet criteria, valve resuspension can be performed prior to graft insertion 1

When Valve Preservation is CONTRAINDICATED

Replace the valve with composite graft if ANY of the following are present 1:

• Ectatic (enlarged) proximal aorta 1
• Pathological changes of valve cusps or aortic wall 1
• Valve reconstruction appears unsafe 1
• Obvious congenital or acquired valve abnormalities 1
• Marfan syndrome with ectatic root (though valve-sparing root remodeling is Class I recommendation in Marfan patients with appropriate expertise) 1

Common Pitfalls

Critical caveat: Valve-sparing operations with aortic root remodeling are more complicated and time-consuming than composite grafting and should only be performed by surgeons with broad experience in elective cases, even though they are Class I recommendations 1. In the emergency setting of acute dissection, prioritize operative survival over complex valve-sparing techniques unless the surgeon has extensive experience 4.

Avoid fibrinous glue for root reconstruction—it has an 8.7-fold increased risk of reoperation compared to GRF-glue or Teflon felt 3. GRF-glue provides durable results with only 11% reoperation rate versus 40% with fibrinous glue 3.