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PostScript

Personalised external aortic root support Dear Editor, Valve replacing and valvesparing root replacement were devised on the operating table and evolved by trial and error. Different times set different standards. By contrast, after 4 years of research collaboration between surgeons, anatomists and engineers (2000–2004), personalised external aortic root support (PEARS) has followed a standard protocol in 42 patients with over 170 patient-years of intention-to-treat analysis, and has been systematically and rigorously evaluated. Cameron’s ‘two technical points’1 do not accurately reflect how this operation is in fact performed.2 The proximal end of the support has a rolled margin sutured to the aorto-ventricular junction, and is far stronger than required to prevent dilatation. Aortic button implantation is a site of failure in root replacement not shared by PEARS which has no sutured button. The soft pliant macroporous mesh, which we know to be histologically incorporated in the aortic adventitia, covers the transition from aorta to coronary artery without constraining it.2 Cameron’s ‘revisiting’ implies that PEARS is to be compared with the historical crude wrapping with stiff vascular grafts or to the Florida sleeve, both of which we consider to be quite different. For valve-sparing root replacement, cardiopulmonary bypass times were more than 3 h for the majority of 239 patients in a recent prospective observational study (Aortic Valve Operative Outcomes in Marfan Patients).3 Certainly, this cannot be considered a ‘short bypass time’. One-year outcomes only are reported. When evaluated in a core lab, 7% of patients had aortic regurgitation of at least moderate severity (≥2+). The 1-year major adverse valverelated event (MAVRE) rate was 16% (35/ 222), and the combined 1-year MAVRE and cardiac complications event rate was 29% (65/225)3 Cameron glosses over the documented long-term composite valverelated event rate for valve-sparing root replacement of 1.9% per annum.4 His ‘high benchmark of surgical success’ conveys Heart July 2014 Vol 100 No 13

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PostScript complacency not warranted on examination of the facts. Root replacement for people with Marfan syndrome has extended survival,1 and has been a surgical achievement in which we have shared, but there is room for reduction in the burden that root replacement surgery places on the quality of patients’ lives.4 The technology of computer aided design is a reliable way of conserving the valve and leaving the blood/endothelial interface intact2 compared with the ‘bench mark’ operation. It offers the prospect of a better quality of life for future patients. Tom Treasure,1 J JM Takkenberg,2 John Pepper3

Correspondence to Professor Tom Treasure, Clinical Operational Research Unit, Department of Mathematics, University College London, London WC1H 0BT, UK; [email protected] Competing interests The authors have no commercial interest in this device and received no remuneration of any kind in the development and evaluation of this device.

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REFERENCES 1 2

Provenance and peer review Not commissioned; internally peer reviewed. 3

To cite Treasure T, Takkenberg JJM, Pepper J. Heart 2014;100:1065–1066.

1

Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK 2 Department of CardioThoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands 3 Department of Cardiac Surgery, Royal Brompton Hospital, London, UK

Heart 2014;100:1065–1066. doi:10.1136/heartjnl-2014-306136

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Cameron D. External support of the dilated aorta: back to the future? Heart 2014;100:908. Pepper J, Petrou M, Rega F, et al. Implantation of an individually computer-designed and manufactured external support for the Marfan aortic root. Multimed Man Cardiothorac Surg 2013:mmt004 doi:10.1093/ mmcts/mmt004 published online March 20, 2013. Coselli JS, Volguina IV, Lemaire SA. Early and one-year outcomes of aortic root surgery in Marfan syndrome patients. A prospective, multicentre, comparative study. J Thorac Cardiovasc Surg 2014. pii: S0022-5223(14) 00181-0. Published Online First. doi: 10.1016/j.jtcvs. 2014.02.021 Benedetto U, Melina G, Takkenberg JJ, et al. Surgical management of aortic root disease in Marfan syndrome: a systematic review and meta-analysis. Heart 2011;97:955–8.

▸ http://dx.doi.org/10.1136/heartjnl-2013-305279

Heart July 2014 Vol 100 No 13

Downloaded from http://heart.bmj.com/ on May 30, 2015 - Published by group.bmj.com

Personalised external aortic root support Tom Treasure, J JM Takkenberg and John Pepper Heart 2014 100: 1065-1066 originally published online May 28, 2014

doi: 10.1136/heartjnl-2014-306136 Updated information and services can be found at: http://heart.bmj.com/content/100/13/1065.2

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Personalised external aortic root support.

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