Eur J Cardiothorac Surg 2006;30:560-562
© 2006 Elsevier Science NL
A simple modification of ‘David-V’ aortic root reimplantation
Shinichi Takamoto*,
Kan Nawata,
Tetsuro Morota
Department of Cardiothoracic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
Received 6 April 2006;
received in revised form 19 June 2006;
accepted 19 June 2006.
* Corresponding author. Address: 113-8655, 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan. Tel.: +81 3 5800 8855; fax: +81 3 5800 8854. (Email: takamoto-tho{at}h.u-tokyo.ac.jp).
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Abstract
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Valve-sparing aortic root reimplantation with creation of Dacron graft pseudosinuses is a popular and promising surgical choice for annuloaortic ectasia or ascending aortic aneurysm. We have developed a simple modification of the David-V technique, which facilitates free adjustment of the size of the new aortic annulus and the pseudosinus of each patient, as well as the creation of pseudosinuses of excellent shape, with only one Dacron graft.
Key Words: Aortic root • David procedure • Aortic surgery • Valve-sparing aortic root replacement • Reimplantation • Pseudosinus
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1. Introduction
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Aortic valve-sparing reimplantation operations in patients with ascending aorta or aortic root aneurysms were first reported by David and Feindel [1]. However, the resulting absence of Valsalva sinuses has attracted criticism as a possible cause of abnormal leaflet stresses that would limit the long-term durability of the native valves. Several modified procedures have been advocated, including methods by Cochran et al. [2], a ‘sinus graft’ by De Paulis and coworkers [3,4], the David-V technique [5] and its simple modification by Miller and Demers [6]. Our modification creates pseudosinuses of Valsalva, using just one straight graft.
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2. Technique
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The entire base of the aortic root is dissected out below the level of the aortic annulus, the sinuses of Valsalva are excised and coronary buttons are fashioned. The diameter of the basal ring and the average height of the three aortic cusps are measured. The proximal end of the graft is measured from the height of the cusps, using David's original formula [1]. In many cases with less than moderate aortic regurgitation, the calculated diameter and the actual diameter of the basal ring do not differ much. A collagen-impregnated woven Dacron graft with a diameter 6 mm larger than the calculated size is trimmed proximally by 6 mm with 4-0 monofilament polyester sutures at three sites, reducing the original diameter by about 6 mm. Fifteen monofilament polyester 4-0 mattress sutures with pledgets, that is, five sutures in each sinus, are placed in the horizontal plane immediately below the lowest level of the valve leaflets in the left ventricular outflow tract, with no gap between adjacent sutures. Then, the aortic root is incorporated inside the graft, and the three pleats of the proximal edge of the graft are placed at the foot of the commissural posts to facilitate firm suturing of the remnant native sinus wall to the interior graft surface. The top of each commissural post is placed inside the graft by a mattress suture, and the position is confirmed by a water test to reduce cusp prolapse as much as possible. The remnant Valsalva wall inside the graft is secured with a 5-0 polypropylene running suture. To form well-shaped pseudosinuses, this suture line should be rounded, that is, U-shaped, not V-shaped. If one of the cusps is elongated and prolapsed still, sutures are added to reinforce the commissure or the Arantius’ nodule for better cusp coaptation. After reimplantation of the coronary arteries, the graft length is adjusted to match the distal anastomosis with the ascending aorta. Then, at the middle of each sinus, longitudinal suture lines are made from the level of the top of the commissures toward the distal end of the graft with running sutures, reducing the distal graft diameter by approximately 6 mm (Fig. 1
). In Marfan patients, the distal ascending aorta is wrapped with the rest of the graft material.
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Fig. 1. Intraoperative photograph and diagram illustrating shape of graft just before distal anastomosis in valve-sparing aortic root replacement with modified David-V technique. (Left) The distal part of the graft is narrowed by longitudinal running sutures (black arrows). The left and right coronary artery buttons are visible in the graft pseudosinuses (white and black arrowheads, respectively). (Right) A diagram of the graft.
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3. Results
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Since February 2004, we have employed this maneuver in 16 consecutive patients, 12 Marfan and 4 non-Marfan patients, and none has died. In five, aortic valve repairs using additional sutures on the Arantius’ nodule or commissures were also performed. The size of the grafts utilized for the latest 10 patients was 32 mm in all except two (30 and 34 mm). Echocardiography before discharge revealed no aortic insufficiency in 10 patients, but minimal and mild aortic insufficiency was seen in each three. Three-dimensional computed tomography reveals pseudosinuses similar in shape to the normal aortic root (Fig. 2
). Since our sutures at the lowest edge of the conduit are made secure for hemostasis, a homologous blood transfusion was performed in only four (25%) with autologous blood storage.
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Fig. 2. Postoperative three-dimensional computed tomogram of left ventricle and thoracic aorta from left anterior oblique angle, demonstrating bulging graft pseudosinuses (arrowheads) in reconstructed aortic root, and abrupt narrowing due to longitudinal running sutures, representing neo-sinotubular junction (arrows). Note that the right and left pseudosinuses are clearly separated.
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4. Discussion
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Valve-sparing aortic root replacements were reported by Yacoub [7] and David [1]. The main issues were the presence of the Valsalva sinuses, the number of suture lines (which affects the likelihood of bleeding), and the preventive effect of long-term annular dilatation. We report a simple reimplantation technique that includes pseudosinus construction, using a single graft. Our three longitudinal size-reduction sutures to the distal end of the graft permit natural flow beyond the sinotubular junction, in contrast to the localized sutures only at the sinotubular junction of the original David-V technique [5]. Fewer anastomoses are used than in the two-graft method of Miller and Demers [6], reducing the operation time and the chance of bleeding. Furthermore, there are two advantages over the ready-made ‘Valsalva graft’ [3,4]: first, as in Miller's modification, the distal end of the graft has a large diameter, so reimplantation suturing of the valves inside the graft can be done very comfortably; and second, pseudosinuses are created after the heights of the commissural posts are determined, so that their size can be decided freely in the operating room. What must be kept in mind is that the positions of the three commissures, the sutures on the subcusp line and the size-reduction sutures toward the distal part of the graft should be determined according to the natural ratio of the sinus sizes. As the short-term results of our simple modification of David-V are satisfactory in regard to postoperative aortic insufficiency and the reduced frequency of homologous blood transfusions, this method is a useful alternative for valve-sparing aortic root replacement.
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References
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- 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;103:617-621.[Abstract]
- Cochran RP, Kunzelman KS, Eddy AC, Hofer BO, Verrier ED. Modified conduit preparation creates a pseudosinus in an aortic valve-sparing procedure for aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1995;109:1049-1057.[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]
- 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]
- David TE. Aortic valve sparing operations. Ann Thorac Surg 2002;73:1029-1030.[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]
- Yacoub MH, Fagan A, Stassano P, Radley-Smith R. Results of valve conserving operations for aortic regurgitation. Circulation 1983;68:III-321.[Medline]
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Abstract
1. Introduction
