Florida Sleeve, Bicuspid Valve Repair, and Proximal Arch Aneurysm Repair

Certain ascending aneurysms have a dominant burden in the tubular ascending segment, but also have involvement of either, or both, the root and arch to a much lesser extent. In this video, a 52-year-old otherwise healthy man with mild aortic stenosis of the bicuspid aortic valve and 2+ eccentric aortic insufficiency, was noted to have aortic dimensions of: 4.3 cm aortic root, 5.3 cm tubular ascending, and 4.1 cm innominate artery origin. Current guidelines do not capture every clinical scenario, but generally would support tubular ascending aortic resection, and probably valve intervention (class IIa) as well. Formal root replacement (Bentall or re-implantation (David) procedure) or hemi-arch replacement with circulatory arrest would not necessarily be supported. The extent of the surgery and associated risks need to be balanced against the risk of future larger aneurysms in any non-resected modestly dilated segments. A reasonable compromise is a Florida sleeve valve-sparing aortic root repair (inclusion technique), repair of the leaking bicuspid valve with raphe shaving, virtual basal ring annuloplasty and leaflet plication, and ascending through proximal arch replacement with alternate (dual) aortic cannulation/clamping (no circulatory arrest). All segments were treated with a 34 mm Dacron graft.