General Thoracic and Cardiovascular Surgery

, Volume 67, Issue 1, pp 82–92 | Cite as

Valve-sparing aortic root surgery. CON: remodeling

  • Takashi KuniharaEmail author
SPECIAL EDITION Controversies in Surgery for Thoracic Aorta


The two major valve-sparing root replacement procedures, aortic valve reimplantation (reimplantation) and aortic root remodeling (remodeling), have advantages and disadvantages, which are reviewed herein. The main advantage of reimplantation is the resulting annular support, and the disadvantages are the unfavorable hemodynamics and relatively long procedure time. The main advantages of remodeling are the physiological hemodynamics and decreased procedure time, and the disadvantage is the lack of annular support. With technical advances and modifications, however, the differences between these two procedures have narrowed. Application of a graft with sinuses for reimplantation improves the hemodynamics, and addition of annuloplasty to remodeling provides the necessary annular support. Nevertheless, remodeling has some advantages because less root dissection is required and the procedure time is shorter and hemodynamically favorable. Thus, remodeling may be the procedure of choice for high-risk patients (such as those with acute aortic dissection, of advanced age, with reduced ventricular function, or undergoing a concomitant operation). Remodeling may also be best for young athletes because of the hemodynamic advantage. Regardless of the advantages and disadvantages, both procedures provide excellent clinical results in terms of late valve durability. Surgeons should be familiar with both techniques and properly match patients to the appropriate treatment.


Aortic root remodeling Aortic valve reimplantation Valve-preserving root replacement Aortic valve repair Annuloplasty 


Compliance with ethical standards

Conflict of interest

The author has declared no competing interest.


  1. 1.
    David TE, Feindel CM. An aortic-valve sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 1992;103:617–22.Google Scholar
  2. 2.
    Sarsam MA, Yacoub M. Remodeling of the aortic anulus. J Thorac Cardiovasc Surg. 1993;105:435–8.Google Scholar
  3. 3.
    David TE. Aortic valve haemodynamics after aortic valve-sparing operations. Eur J Cardiothorac Surg. 2012;41:788–9.CrossRefGoogle Scholar
  4. 4.
    Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg. 1998;115:1080–90.CrossRefGoogle Scholar
  5. 5.
    El Khoury GA, Underwood MJ, Glineur D, Derouck D, Dion RA. Reconstruction of the ascending aorta and aortic root: experience in 45 consecutive patients. Ann Thorac Surg. 2000;70:1246–50.CrossRefGoogle Scholar
  6. 6.
    Schäfers HJ, Raddatz A, Schmied W, Takahashi H, Miura Y, Kunihara T, et al. Reexamining remodeling. J Thorac Cardiovasc Surg. 2015;149:S30–6.CrossRefGoogle Scholar
  7. 7.
    Lansac E, Di Centa I, Sleilaty G, Lejeune S, Berrebi A, Zacek P, et al. Remodeling root repair with an external aortic ring annuloplasty. J Thorac Cardiovasc Surg. 2017;153:103–42.CrossRefGoogle Scholar
  8. 8.
    Schneider U, Aicher D, Miura Y, Schäfers HJ. Suture annuloplasty in aortic valve repair. Ann Thorac Surg. 2016;101:783–5.CrossRefGoogle Scholar
  9. 9.
    Mazzitelli D, Fischlein T, Rankin JS, Choi YH, Stamm C, Pfeiffer S, et al. Geometric ring annuloplasty as an adjunct to aortic valve repair: clinical investigation of the HAART 300 device. Eur J Cardiothorac Surg. 2016;49:987–93.CrossRefGoogle Scholar
  10. 10.
    Leyh RG, Fischer S, Kallenbach K, Kofidis T, Pethig K, Harringer W, et al. High failure rate after valve-sparing aortic root replacement using the “remodeling technique” in acute type A aortic dissection. Circulation. 2002;106(12 Suppl 1):I229–I33.Google Scholar
  11. 11.
    Jeanmart H, de Kerchove L, Glineur D, Goffinet JM, Rougui I, Van Dyck M, et al. Aortic valve repair: the functional approach to leaflet prolapse and valve-sparing surgery. Ann Thorac Surg. 2007;83:S746–51.CrossRefGoogle Scholar
  12. 12.
    Hanke T, Charitos EI, Stierle U, Robinson D, Gorski A, Sievers HH, et al. Factors associated with the development of aortic valve regurgitation over time after two different techniques of valve-sparing aortic root surgery. J Thorac Cardiovasc Surg. 2009;137:314–9.CrossRefGoogle Scholar
  13. 13.
    Kunihara T, Aicher D, Rodionycheva S, Groesdonk HV, Langer F, Sata F, et al. Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valve-preserving aortic root repair. J Thorac Cardiovasc Surg. 2012;143:1389–95.CrossRefGoogle Scholar
  14. 14.
    Svensson LG, Batizy LH, Blackstone EH, Gillinov AM, Moon MC, D’Agostino RS, et al. Results of matching valve and root repair to aortic valve and root pathology. J Thorac Cardiovasc Surg. 2011;142:1491–8. :.e7.CrossRefGoogle Scholar
  15. 15.
    David TE, Feindel CM, David CM, Manlhiot C. A quarter of a century of experience with aortic valve-sparing operations. J Thorac Cardiovasc Surg. 2014;148:872–9.CrossRefGoogle Scholar
  16. 16.
    Svensson LG, Deglurkar I, Ung J, Pettersson G, Gillinov AM, D’Agostino RS, et al. Aortic valve repair and root preservation by remodeling, reimplantation, and tailoring: technical aspects and early outcome. J Card Surg. 2007;22:473–9.CrossRefGoogle Scholar
  17. 17.
    de Kerchove L, Mastrobuoni S, Boodhwani M, Astarci P, Rubay J, Poncelet A, et al. The role of annular dimension and annuloplasty in tricuspid aortic valve repair. Eur J Cardiothorac Surg. 2016;49:428–37.CrossRefGoogle Scholar
  18. 18.
    Aicher D, Kunihara T, Abou Issa O, Brittner B, Gräber S, Schäfers HJ. Valve configuration determines long-term results after repair of the bicuspid aortic valve. Circulation. 2011;123:178–85.CrossRefGoogle Scholar
  19. 19.
    Cabrol C, Cabrol A, Guiraudon G, Bertrand M. Treatment of aortic insufficiency by means of aortic annuloplasty. Arch Mal Coeur Vaiss. 1966;59:1305–12.Google Scholar
  20. 20.
    David TE. Aortic root aneurysms: remodeling or composite replacement? Ann Thorac Surg. 1997;64:1564–8.CrossRefGoogle Scholar
  21. 21.
    de Kerchove L, Boodhwani M, Glineur D, Vandyck M, Vanoverschelde JL, Noirhomme P, et al. Valve sparing-root replacement with the reimplantation technique to increase the durability of bicuspid aortic valve repair. J Thorac Cardiovasc Surg. 2011;142:1430–8.CrossRefGoogle Scholar
  22. 22.
    Navarra E, El Khoury G, Glineur D, Boodhwani M, Van Dyck M, Vanoverschelde JL, et al. Effect of annulus dimension and annuloplasty on bicuspid aortic valve repair. Eur J Cardiothorac Surg. 2013;44:316–22.CrossRefGoogle Scholar
  23. 23.
    Vallabhajosyula P, Komlo CM, Szeto WY, Rhode T, Menon R, Desai ND, et al. Aortic annulus diameter affects durability of the repaired bicuspid aortic valve. J Heart Valve Dis. 2015;24:412–9.Google Scholar
  24. 24.
    Schneider U, Schmied W, Aicher D, Giebels C, Winter L, Schäfers HJ. Sinus plication to improve valve configuration in bicuspid aortic valve repair-early results. Ann Thorac Surg. 2017;103:580–5.CrossRefGoogle Scholar
  25. 25.
    Holubec T, Higashigaito K, Belobradek Z, Dergel M, Harrer J, Alkadhi H, et al. An expansible aortic ring in aortic remodeling: exact position, pulsatility, effectiveness, and stability in three-dimensional CT study. Ann Thorac Surg. 2017;103:83–90.CrossRefGoogle Scholar
  26. 26.
    Cameron D. Why can not the aortic valve be more like the mitral? Eur J Cardiothorac Surg. 2016;49:994.CrossRefGoogle Scholar
  27. 27.
    Izumoto H, Kawazoe K, Oka T, Ishibashi K, Yamamoto H, Yamamoto F. Leaflet suspension and subvalvular annuloplasty in aortic valve prolapse. Asian Cardiovasc Thorac Ann. 2009;17:278–81.CrossRefGoogle Scholar
  28. 28.
    Erasmi A, Sievers HH, Scharfschwerdt M, Eckel T, Misfeld M. In vitro hydrodynamics, cusp-bending deformation, and root distensibility for different types of aortic valve-sparing operations: remodeling, sinus prosthesis, and reimplantation. J Thorac Cardiovasc Surg. 2005;130:1044–9.CrossRefGoogle Scholar
  29. 29.
    Wuliya M, Sleilaty G, Di Centa I, Khelil N, Berrebi A, Czitrom D, et al. An expansible aortic ring to preserve aortic root dynamics after aortic valve repair. Eur J Cardiothorac Surg. 2015;47:482–90.CrossRefGoogle Scholar
  30. 30.
    Kunzelman KS, Grande KJ, David TE, Cochran RP, Verrier ED. Aortic root and valve relationships. Impact on surgical repair. J Thorac Cardiovasc Surg. 1994;107:162–70.Google Scholar
  31. 31.
    Lansac E, Lim HS, Shomura Y, Lim KH, Rice NT, Goetz W, et al. A four-dimensional study of the aortic root dynamics. Eur J Cardiothorac Surg. 2002;22:497–503.CrossRefGoogle Scholar
  32. 32.
    Cheng A, Dagum P, Miller DC. Aortic root dynamics and surgery: from craft to science. Philos Trans R Soc Lond B Biol Sci. 2007;362:1407–19.CrossRefGoogle Scholar
  33. 33.
    Matsumori M, Tanaka H, Kawanishi Y, Onishi T, Nakagiri K, Yamashita T, et al. Comparison of distensibility of the aortic root and cusp motion after aortic root replacement with two reimplantation techniques: valsalva graft versus tube graft. Interact Cardiovasc Thorac Surg. 2007;6:177–81.CrossRefGoogle Scholar
  34. 34.
    De Paulis R, De Matteis GM, Nardi P, Scaffa R, Bassano C, Chiariello L. Analysis of valve motion after the reimplantation type of valve-sparing procedure (David I) with a new aortic root conduit. Ann Thorac Surg. 2002;74:53–7.CrossRefGoogle Scholar
  35. 35.
    Basmadjian L, Basmadjian AJ, Stevens LM, Mongeon FP, Cartier R, Poirier N, et al. Early results of extra-aortic annuloplasty ring implantation on aortic annular dimensions. J Thorac Cardiovasc Surg. 2016;151:1280–5.CrossRefGoogle Scholar
  36. 36.
    Fries R, Graeter T, Aicher D, Reul H, Schmitz C, Böhm M, et al. In vitro comparison of aortic valve movement after valve-preserving aortic replacement. J Thorac Cardiovasc Surg. 2006;132:32–7.CrossRefGoogle Scholar
  37. 37.
    Leyh RG, Schmidtke C, Sievers HH, Yacoub MH. Opening and closing characteristics of the aortic valve after different types of valve-preserving surgery. Circulation. 1999;100:2153–60.CrossRefGoogle Scholar
  38. 38.
    Aybek T, Sotiriou M, Wöhleke T, Miskovic A, Simon A, Doss M, et al. Valve opening and closing dynamics after different aortic valve-sparing operations. J Heart Valve Dis. 2005;14:114–20.Google Scholar
  39. 39.
    Graeter TP, Fries R, Aicher D, Reul H, Schmitz C, Schäfers HJ. In-vitro comparison of aortic valve hemodynamics between aortic root remodeling and aortic valve reimplantation. J Heart Valve Dis. 2006;15:329–35.Google Scholar
  40. 40.
    Vohra HA, Whistance RN, de Kerchove L, Glineur D, Noirhomme P, El Khoury G. Influence of higher valve gradient on long-term outcome after aortic valve repair. Ann Cardiothorac Surg. 2013;2:30–9.Google Scholar
  41. 41.
    Grande-Allen KJ, Cochran RP, Reinhall PG, Kunzelman KS. Re-creation of sinuses is important for sparing the aortic valve: a finite element study. J Thorac Cardiovasc Surg. 2000;119:753–63.CrossRefGoogle Scholar
  42. 42.
    Erasmi AW, Sievers HH, Bechtel JF, Hanke T, Stierle U, Misfeld M. Remodeling or reimplantation for valve-sparing aortic root surgery? Ann Thorac Surg. 2007;83:S752–6.CrossRefGoogle Scholar
  43. 43.
    David TE, Maganti M, Armstrong S. Aortic root aneurysm: principles of repair and long-term follow-up. J Thorac Cardiovasc Surg. 2010;140:S14–9.CrossRefGoogle Scholar
  44. 44.
    Kallenbach K, Karck M, Pak D, Salcher R, Khaladj N, Leyh R, et al. Decade of aortic valve sparing reimplantation: are we pushing the limits too far? Circulation. 2005;112(9 Suppl):I253–I9.Google Scholar
  45. 45.
    Leontyev S, Trommer C, Subramanian S, Lehmann S, Dmitrieva Y, Misfeld M, et al. The outcome after aortic valve-sparing (David) operation in 179 patients: a single-centre experience. Eur J Cardiothorac Surg. 2012;42:261–6.CrossRefGoogle Scholar
  46. 46.
    Liebrich M, Kruszynski MK, Roser D, Meisner C, Doll KN, Hemmer WB, et al. The David procedure in different valve pathologies: a single-center experience in 236 patients. Ann Thorac Surg. 2013;95:71–6.CrossRefGoogle Scholar
  47. 47.
    Kvitting JP, Kari FA, Fischbein MP, Liang DH, Beraud AS, Stephens EH, et al. David valve-sparing aortic root replacement: equivalent mid-term outcome for different valve types with or without connective tissue disorder. J Thorac Cardiovasc Surg. 2013;145:117–26.CrossRefGoogle Scholar
  48. 48.
    Toeg H, Chan V, Rao RV, Chan KL, Ruel M, Mesana T, et al. Contemporary midterm echocardiographic outcomes of Bentall procedure and aortic valve sparing root replacement. Ann Thorac Surg. 2014;98:590–6.CrossRefGoogle Scholar
  49. 49.
    Coselli JS, Hughes MS, Green SY, Price MD, Zarda S, de la Cruz KI, et al. Valve-sparing aortic root replacement: early and midterm outcomes in 83 patients. Ann Thorac Surg. 2014;97:1267–73.CrossRefGoogle Scholar
  50. 50.
    Miyahara S, Matsueda T, Izawa N, Yamanaka K, Sakamoto T, Nomura Y, et al. Mid-term results of valve-sparing aortic root replacement in patients with expanded indications. Ann Thorac Surg. 2015;100:845–51.CrossRefGoogle Scholar
  51. 51.
    Koolbergen DR, Manshanden JS, Bouma BJ, Blom NA, Mulder BJ, de Mol BA, et al. Valve-sparing aortic root replacement. Eur J Cardiothorac Surg. 2015;47:348–54.CrossRefGoogle Scholar
  52. 52.
    De Paulis R, Chirichilli I, Scaffa R, Weltert L, Maselli D, Salica A, et al. Long-term results of the valve reimplantation technique using a graft with sinuses. J Thorac Cardiovasc Surg. 2016;151:112–9.CrossRefGoogle Scholar
  53. 53.
    Esaki J, Leshnower BG, Binongo JN, Lasanajak Y, McPherson L, Halkos ME, et al. Clinical outcomes of the David V valve-sparing root replacement compared with bioprosthetic valve-conduits for aortic root aneurysms. Ann Thorac Surg. 2016. S0003-4975(16)31307–8. doi: 10.1016/j.athoracsur.2016.09.055.Google Scholar
  54. 54.
    David TE, David CM, Feindel CM, Manlhiot C. Reimplantation of the aortic valve at 20 years. J Thorac Cardiovasc Surg. 2017;153:232–8.CrossRefGoogle Scholar
  55. 55.
    Arabkhani B, Mookhoek A, Di Centa I, Lansac E, Bekkers JA, Van Wijngaarden RDL, et al. Reported outcome after valve-sparing aortic root replacement for aortic aneurysm: a systematic review and meta-analysis. Ann Thorac Surg. 2015;100:1126–31.CrossRefGoogle Scholar
  56. 56.
    Kari FA, Doll KN, Hemmer W, Liebrich M, Sievers HH, Richardt D, et al. Residual and progressive aortic regurgitation after valve-sparing root replacement: a propensity-matched multi-institutional analysis in 764 patients. Ann Thorac Surg. 2016;101:1500–6.CrossRefGoogle Scholar
  57. 57.
    Forteza A, Vera F, Centeno J, López-Gude MJ, Pérez-de la Sota E, Sánchez V, et al. Preservation of the bicuspid aortic valve associated with aneurysms of the aortic root and ascending aorta. Rev Esp Cardiol (Engl Ed). 2013;66:64–8.CrossRefGoogle Scholar
  58. 58.
    Kari FA, Liang DH, Kvitting JP, Stephens EH, Mitchell RS, Fischbein MP, et al. Tirone David valve-sparing aortic root replacement and cusp repair for bicuspid aortic valve disease. J Thorac Cardiovasc Surg. 2013;145(3 Suppl):S35–40.e1.CrossRefGoogle Scholar
  59. 59.
    Richardt D, Stierle U, Sievers HH. Long-term results after aortic valve-sparing-reimplantation operation (David) in bicuspid aortic valve. J Heart Valve Dis. 2015;24:4–9.Google Scholar
  60. 60.
    Vallabhajosyula P, Szeto WY, Habertheuer A, Komlo C, Milewski RK, McCarthy F, et al. Bicuspid aortic insufficiency with aortic root aneurysm: root reimplantation versus Bentall root replacement. Ann Thorac Surg. 2016;102:1221–8.CrossRefGoogle Scholar
  61. 61.
    Miyahara S, Abe N, Matsueda T, Izawa N, Yamazato T, Nomura Y, et al. Impact of positional relationship of commissures on cusp function after valve-sparing root replacement for regurgitant bicuspid aortic valve. Eur J Cardiothorac Surg. 2016;50:75–81.CrossRefGoogle Scholar
  62. 62.
    Fattouch K, Moscarelli M, Castrovinci S, Murana G, Dioguardi P, Guccione F, et al. Mid-term results of bicuspid aortic valve repair guided by morphology and function assessment. Interact Cardiovasc Thorac Surg. 2017. doi: 10.1093/icvts/ivx027.Google Scholar
  63. 63.
    Schneider U, Feldner SK, Hofmann C, Schöpe J, Wagenpfeil S, Giebels C, et al. Two decades of experience with root remodeling and valve repair for bicuspid aortic valves. J Thorac Cardiovasc Surg. 2017;153:S65–71.CrossRefGoogle Scholar
  64. 64.
    Aicher D, Schneider U, Schmied W, Kunihara T, Tochii M, Schäfers HJ. Early results with annular support in reconstruction of the bicuspid aortic valve. J Thorac Cardiovasc Surg. 2013;145(3 Suppl):S30–4.CrossRefGoogle Scholar
  65. 65.
    Benedetto U, Melina G, Takkenberg JJ, Roscitano A, Angeloni E, Sinatra R. Surgical management of aortic root disease in Marfan syndrome: a systematic review and meta-analysis. Heart. 2011;97:955–8.CrossRefGoogle Scholar
  66. 66.
    Tanaka H, Ogino H, Matsuda H, Minatoya K, Sasaki H, Iba Y. Midterm outcome of valve-sparing aortic root replacement in inherited connective tissue disorders. Ann Thorac Surg. 2011;92:1646–9.CrossRefGoogle Scholar
  67. 67.
    Kunihara T, Aicher D, Rodionycheva S, Asano M, Tochii M, Sata F, et al. Outcomes after valve-preserving root surgery for patients with Marfan syndrome. J Heart Valve Dis. 2012;21:615–22.Google Scholar
  68. 68.
    Schmidtke C, Karluss A, Sier H, Hüppe M, Brauer K, Sievers HH. Mid-term results of different aortic valve-sparing procedures in Marfan syndrome. J Heart Valve Dis. 2012;21:195–201.Google Scholar
  69. 69.
    Schoenhoff FS, Langhammer B, Wustmann K, Reineke D, Kadner A, Carrel T. Decision-making in aortic root surgery in Marfan syndrome: bleeding, thromboembolism and risk of reintervention after valve-sparing or mechanical aortic root replacement. Eur J Cardiothorac Surg. 2015;48:931–5.CrossRefGoogle Scholar
  70. 70.
    David TE, David CM, Manlhiot C, Colman J, Crean AM, Bradley T. Outcomes of aortic valve-sparing operations in Marfan syndrome. J Am Coll Cardiol. 2015;66:1445–53.CrossRefGoogle Scholar
  71. 71.
    Price J, Magruder JT, Young A, Grimm JC, Patel ND, Alejo D, et al. Long-term outcomes of aortic root operations for Marfan syndrome: a comparison of Bentall versus aortic valve-sparing procedures. J Thorac Cardiovasc Surg. 2016;151:330–6.CrossRefGoogle Scholar
  72. 72.
    Coselli JS, Volguina IV, LeMaire SA, Sundt TM, Connolly HM, Stephens EH, Aortic Valve Operative Outcomes in Marfan Patients Study Group et al. Early and 1-year outcomes of aortic root surgery in patients with Marfan syndrome: a prospective, multicenter, comparative study. J Thorac Cardiovasc Surg. 2014;147:1758–67.CrossRefGoogle Scholar
  73. 73.
    Richardt D, Karluss A, Schmidtke C, Sievers HH, Scharfschwerdt M. A new sinus prosthesis for aortic valve-sparing surgery maintaining the shape of the root at systemic pressure. Ann Thorac Surg. 2010;89:94–6.CrossRefGoogle Scholar
  74. 74.
    Saczkowski R, Malas T, Mesana T, de Kerchove L, El Khoury G, Boodhwani M. Aortic valve preservation and repair in acute Type A aortic dissection. Eur J Cardiothorac Surg. 2014;45:e220–e6.CrossRefGoogle Scholar
  75. 75.
    Graeter TP, Langer F, Nikoloudakis N, Aicher D, Schäfers HJ. Valve-preserving operation in acute aortic dissection type A. Ann Thorac Surg. 2000;70:1460–5.CrossRefGoogle Scholar
  76. 76.
    Erasmi AW, Stierle U, Bechtel JF, Schmidtke C, Sievers HH, Kraatz EG. Up to 7 years’ experience with valve-sparing aortic root remodeling/reimplantation for acute type A dissection. Ann Thorac Surg. 2003;76:99–104.CrossRefGoogle Scholar
  77. 77.
    Kallenbach K, Oelze T, Salcher R, Hagl C, Karck M, Leyh RG, et al. Evolving strategies for treatment of acute aortic dissection type A. Circulation. 2004;110(11 Suppl 1):II243–I9.Google Scholar
  78. 78.
    Farhat F, Durand M, Boussel L, Sanchez I, Villard J, Jegaden O. Should a reimplantation valve sparing procedure be done systematically in type A aortic dissection? Eur J Cardiothorac Surg. 2007;31:36–41.CrossRefGoogle Scholar
  79. 79.
    Subramanian S, Leontyev S, Borger MA, Trommer C, Misfeld M, Mohr FW. Valve-sparing root reconstruction does not compromise survival in acute type A aortic dissection. Ann Thorac Surg. 2012;94:1230–4.CrossRefGoogle Scholar
  80. 80.
    Urbanski PP, Lenos A, Irimie V, Bougioukakis P, Zacher M, Diegeler A. Acute aortic dissection involving the root: operative and long-term outcome after curative proximal repair. Interact Cardiovasc Thorac Surg. 2016;22:620–-6.CrossRefGoogle Scholar
  81. 81.
    Leshnower BG, Myung RJ, McPherson L, Chen EP. Midterm results of David V valve-sparing aortic root replacement in acute type A aortic dissection. Ann Thorac Surg. 2015;99:795–800.CrossRefGoogle Scholar
  82. 82.
    Beckmann E, Martens A, Alhadi FA, Ius F, Koigeldiyev N, Fleissner F, et al. Is Bentall procedure still the gold standard for acute aortic dissection with aortic root involvement? Thorac Cardiovasc Surg. 2016;64:116–23.CrossRefGoogle Scholar
  83. 83.
    Kunihara T, Neumann N, Kriechbaum SD, Aicher D, Schäfers HJ. Aortic root remodeling leads to good valve stability in acute aortic dissection and preexistent root dilatation. J Thorac Cardiovasc Surg. 2016;152:430–6.e1.CrossRefGoogle Scholar

Copyright information

© The Japanese Association for Thoracic Surgery 2017

Authors and Affiliations

  1. 1.The Cardiovascular InstituteTokyoJapan

Personalised recommendations