Reply to Baikoussis et al.

We appreciate the interest in our study expressed by Baikoussis et al. [1] and thank them very much for their comments. Our study aimed at investigating the short- and long-term outcomes of aortic valve-sparing root replacement (David procedure) in patients with bicuspid aortic valve [2]. Baikoussis et al. addressed two issues concerning our article.

First, all patients who underwent the David procedure in this study received a straight tube graft. Baikoussis et al. have expressed concerns about the use of a straight tube graft and suggest using a prosthesis with preformed sinuses of Valsalva instead. Although preformed sinuses offer more physiological haemodynamics, in theory, no study could ever demonstrate that these theoretical advantages translate into a clinical benefit in terms of improved durability of the preserved aortic valve. Indeed, we have recently published a study comparing the two graft types when used for the David procedure, and our data suggested that the straight tube graft is not inferior to a graft with preformed sinuses of Valsalva [3]. Furthermore, David [4], the inventor of this procedure, had excellent results with his original technique using a straight tube graft. We agree with his conclusion that ‘the outcome is probably more dependent on the surgeon’s ability to restore a functionally reasonable anatomic arrangement among the various components of the aortic root than on the type of graft used’ [4].

Second, Baikoussis et al. suggested using a caliper for aortic valve-sparing root replacement. We give credit to Hans Joachim Schäfers for introducing this helpful tool to simplify and standardize aortic valve-sparing surgery. We agree with Baikoussis et al.’s comment that the use of a caliper could prove to be very useful to assess coaptation height, and thus improve the postoperative outcome. However, as described in the methods section of our article, our study comprises patients who underwent surgery from July 1993 to October 2015. The caliper was introduced in 2006, meaning that the majority of operations in this study were performed before the caliper was available.

Finally, we would also like to address another point raised by Baikoussis et al., who write that ‘the results in patients with Marfan syndrome or (…) in patients with acute aortic dissection could not be as good as in patients with simple dilatation of the root’. Patients with Marfan syndrome or patients with acute dissection are usually young and present with structurally intact aortic valves, thus making them ideal candidates for valve-sparing operation. Indeed, our group has previously shown that the long-term performance of the reimplanted aortic valve is not compromised in these two patient cohorts [5, 6].

Again, we thank Baikoussis et al. for their thoughtful comments and suggestions and hope that we have addressed all issues raised and answered all open questions.

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