Aortic Root Aneurysms  Surgical Treatments
At NewYork-Presbyterian Hospital/Columbia University Medical Center (NYPH/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, including:
- 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.
- 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 donor 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.
- Mechanical valve conduit:
Replacement of the entire aorta root and aortic valve with a combination of a mechanical valve with an attached tube graft.
This approach is often used in younger patients or in those patients who wish to avoid reoperation.
Anticoagulation therapy is required.
- Transcatheter Aortic Valve Relacement:
Replacement of the aortic valve in patients with severe aortic stenosis.
The procedure is conducted minimally invasively using a catheter inserted either through a small incision in the groin or a small incision in the chest.
- Endovascular Stent Graft Aneurysm Repair
A minimally invasive procedure to reline and reinforce a weakness in the aortic wall (aneurysm).
Benefits of the procedure include less risk, shorter hospital stay, and more rapid recovery, compared to open-heart aneurysm repair.
David Procedure
For the David procedure, the patient is placed on the heart-lung machine (cardiopulmonary bypass), which takes over the function of the hearts and lungs during the operation.
The heart is cooled and stopped and a clamp is placed across the aortic valve.
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.
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.
The valve is then carefully positioned within the graft to eliminate leaking.
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.
Finally, 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).
(To learn more about ACP, please click here.)
Homograft 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 distal (far) attachment of donated aortic root are identical to the approached used in the David procedure.
Mechanical Valve Conduit
The surgical procedure for a mechanical valve conduit is identical to that of a homograft replacement.
In place of the donated valve, however, an appropriate mechanical valve conduit is selected and the connections are carefully constructed.
Transcatheter Aortic Valve Relacement
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The Edwards Sapien transcatheter aortic heart valve integrates balloon-expandable stent technology with a replacement tissue heart valve. |
During the procedure, a catheter is advanced to the aortic valve, either through the femoral artery or transapically, through a small chest incision and through the left ventricle.
Once the catheter is in place, a tissue valve with metal stent scaffolding is positioned and deployed.
X-ray guidance provides indirect visualization.
The force of the expanding stent anchors the new valve in place, completely avoiding the need for sutures, cardiopulmonary bypass, open surgery—and their associated effects.
Endovascular Stent Graft Aneurysm Repair
Traditionally, repairing a descending thoracic aortic aneurysm (in the chest) required high-risk open heart surgery and involved a large chest incision.
Patients experienced long hospital stays, and recovery was painful.
In this minimally invasive procedure, a stent graft comprised of a layer of impermeable reinforcement material enclosed by a self-expanding metal support mesh is placed at the aneurysm site.
To implant the stent graft, the physician inserts a catheter through the femoral artery in the groin. The stent graft is then delivered through the catheter in a collapsed state and deployed at the site of the aneurysm.
The device replaces and reinforces the diseased aortic wall, ensuring continuity of blood flow. The benefits of the procedure include greatly reduced risk, a shorter hospital stay, and a more rapid recovery.
NewYork-Presbyterian-Columbia participates in the Bolton-RELAY stent graft clinical trial. Read more about the trial.
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