Eur J Cardiothorac Surg 2005;27:925-926
© 2005 Elsevier Science NL
A simple method to adapt the height of the sinotubular junction of the De Paulis Valsalva graft to the height of the patient's sinuses in David reimplantation procedure
Alessandro Mazzola*,
Renato Gregorini,
Carmine Villani,
Raffaele Giancola
Department of Cardiac Surgery, G. Mazzini Hospital, 64100 Teramo, Italy
Received 3 December 2004;
received in revised form 28 January 2005;
accepted 2 February 2005.
* Corresponding author. Tel.: +39 0861 429 690; fax: +39 0861 429 687. (E-mail: sandromaz{at}tin.it).
 |
Abstract
|
|---|
De Paulis and associated introduced a new aortic root conduit for valve-sparing operation. The use of this prosthesis for David I (reimplantation) procedure occasionally may be problematic when the top of the commissures, do not match the new sinotubular junction of the graft. We propose a simple method that allows to create a new sinotubular junction at the desired level in the skirt portion of the Valsalva prosthesis.
Key Words: Aortic valve-sparing procedure • Aortic root surgery
|
1. Introduction
|
|---|
Aortic valve-sparing operation has became the gold standard treatment of root aneurysm when the aortic valve leaflets are normal. The remodelling procedure proposed by Sarsam and Yacoub does not prevent late annular dilatation [1]. The reimplantation procedure ‘T.David I’ is an alternative that provides annular stabilization [2]. The cylindrical shape of the new root in classical T. David I operation predisposes the leaflets to stress so that many variations have been made to the original technique [3–6]. De Paulis introduced a new manufactured prosthesis (Gealweave Valsalva; Sulzer Vascutek, Renfrewshire, Scotland) with a compliant proximal segment [7]. Because the height of the skirt is predetermined in the prosthesis and the height of the sinuses is individually different there is some concern to implant the commissures to the new sinotubular junction [6,8]. We describe a simple method that allows to tailor a new sinotubular junction in the De Paulis Valsalva conduit when the height of the patient sinuses are shorter than the height of the skirt.
|
2. Technique
|
|---|
After the excision of the diseased aortic wall and sinuses a Valsalva graft is selected. The collar is implanted in the left ventricular outflow tract to stabilize the aortic annulus. The distal tubular graft is cut 1–2cm above the skirt. If the commissures do not reach the level of the graft sinotubular junction, three horizontal U stitches are passed at the top of each commissure, then from the inside to the outside at the desired height in the skirt and again from the outside to the inside at the top of the graft (Fig. 1A). Knotting the three stitches the free margin of the tubular prosthesis is lowered at the level of the commissures creating a new sinotubular junction on the skirt (Fig. 1B). The double layer at this level creates a little reduction of the diameter of the sinotubular junction as in a normal aortic root. The remnant of the tubular graft can be utilized to replace the aneurysmatic ascending aorta.
View larger version (66K):
[in this window]
[in a new window]
|
Fig. 1. Clarifying model of the procedure. (A) The stitches anchoring the commissural posts are passed from the inside to the outside in the skirt and again from the outside to the inside at the top of the graft. (B) When the three stitches are knotted a new sinotubular junction is created on the skirt at the level of the commissures. The black lines represent the remnants of the aortic root.
|
|
Case 1. A 47-year-old woman with Marfan's syndrome suffering from ascending aorta aneurysm with normal aortic valve and severe mitral regurgitation caused by annular dilatation and prolapse of both leaflets was operated on using this artefact. In addition an Alfieri mitral valve repair was carried out. Case 2. A 60-year-old man with aneurysm of the aortic root associated with aortic valve regurgitation caused by the sinotubular junction dilatation and prolapse of the non-coronary leaflet underwent aortic root reimplantation with the same technique. The prolapsing leaflet was repaired by central plication and free margin reinforcement. Postoperative echocardiography showed no aortic regurgitation in both cases. The postoperative Magnetic Resonance image showed: in the oblique sagittal plane the bulging of the pseudosinuses and the normal morphologic appearance of the new sinotubular junction (Fig. 2A); in the oblique axial plane, the clover shape of the sinuses proves the compliant nature of the new root (Fig. 2B); although a flow analysis has not been estimated, it seems, from the images, that there are no major turbulences at the level of the new sinotubular junction.
View larger version (103K):
[in this window]
[in a new window]
|
Fig. 2. Magnetic resonance T2-wTSE images. (A) Oblique sagittal plane: the reconstructed aortic root with bulging pseudosinuses and the new sinotubular junction are showed. (B) Oblique axial plane: the compliant nature of the new root (asterisk) is proved by the clover shape of the reconstructed pseudosinuses.
|
|
|
3. Discussion
|
|---|
The reimplantation type of aortic valve-sparing operation is the preferred alternative to the Bentall procedure when the aortic valve leaflets are normal [2–7]. Many modifications to the ‘David I’ original work have been proposed to create pseudosinuses with the aim to increase longterm durability of the aortic valve [3–7]. The use of the Valsalva graft introduced by De Paulis and colleagues, appear to be an attractive possibility because the prefashioned compliant neosinuses mimic the normal root physiology. The major drawback for a more widespread use of this graft is the predetermined height of the skirt [6]. In most cases in fact, the height of the valve remnants are shorter than that of the skirted section of the graft [7]; because the commissures must be implanted on the new sinotubular junction, De Paulis suggests to trim the graft collar to a minimum or reimplant the valve in the skirt to allow the commissural posts to meet the sinotubular junction [7,8]. We propose a simple technique to create a new sinotubular junction at the desired level in the skirt of the Valsalva graft. We believe that the proposed method provides a greater flexibility to the De Paulis prosthesis allowing a secure stabilization of the aortic annulus even when the patients'sinuses are shorter than the skirt.
|
References
|
|---|
- Sarsam MAI, Yacoub M. Remodeling of the aortic valve annulus. J Thorac Cardiovasc Surg 1993;105:435-438.[Abstract]
- 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;103:617-622.[Abstract]
- Cochran RP, Kunzelman KS, Eddy AC, Hofer BO, Verrier ED. Modified conduit preparation creates a pseudosins in an aortic valve-sparing procedure for aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1995;109:1049-1058.
- Van Son JAM, Battellini R, Mierzwa M, Walther T, Autshbach R, Mohr FW. Aortic root reconstruction with preservation of native aortic valve and sinuses in aortic root dilatation with aortic regurgitation. J Thorac Cardiovasc Surg 1999;117:1151-1156.[Abstract/Free Full Text]
- David TE, Armstrong S, Ivanov J, Feindel CM, Omran A, Webb G. Result of aortic valve-sparing operations. J Thorac Cardiovasc Surg 2001;122:39-46.[Abstract/Free Full Text]
- Demers P, Miller DC. Simple modification of T David-V valve-sparing aortic root replacement to create graft pseudosinuses. Ann Thorac Surg 2004;78:1479-1481.[Abstract/Free Full Text]
- 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;74:53-57.[Abstract/Free Full Text]
- De Paulis R, De Matteis GM, Nardi P, Scaffa R, Buratta MM, Chiariello L. Opening and closing characteristics of the aortic valve after valve-sparing procedures using a new aortic root conduit. Ann Thorac Surg 2001;72:487-494.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
P. P. Urbanski, X. Zhan, S. Frank, and A. Diegeler
Aortic root reconstruction using new vascular graft
Interactive CardioVascular and Thoracic Surgery,
February 1, 2009;
8(2):
187 - 190.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. Settepani, W. Y. Szeto, D. Pacini, R. De Paulis, L. Chiariello, R. Di Bartolomeo, R. Gallotti, and J. E. Bavaria
Reimplantation Valve-Sparing Aortic Root Replacement in Marfan Syndrome Using the Valsalva Conduit: An Intercontinental Multicenter Study
Ann. Thorac. Surg.,
February 1, 2007;
83(2):
S769 - S773.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Maselli and G. Minzioni
A technique to reposition sinotubular junction in aortic valve reimplantation procedures with the De Paulis Valsalva graft
Eur. J. Cardiothorac. Surg.,
January 1, 2006;
29(1):
107 - 109.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
1. Introduction
