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Letters to the Editor |
Nagoya University Graduate School of Medicine, Cardiac Surgery, 65 Tsurumai, Showa-ku, Nagoya 466-8550, Japan
Received 3 February 2008; accepted 15 April 2008.
* Corresponding author. Tel.: +81 52 744 2376; fax: +81 52 744 2383. (Email: ausui{at}med.nagoya-u.ac.jp).
Key Words: Aorta • Valvular prosthesis • Aortic valve
Albertini et al. reported a modified biological Bentall operation using the double sewing ring technique [1]. They used a Valsalva graft (Gelweave, Valsalva-prosthesis, Vascutec, Terumo) and applied two separate sewing rings. The first ring was used to sew the bioprosthesis onto the vascular graft and the second one was to fix the vascular graft to the native aortic annulus. In case of a redo surgery, the bioprosthesis may be removed easily by cutting the first ring and fixing a new prosthesis as well.
This procedure was administered for a young lady with congenital aortic valve stenosis. Congenital aortic valve stenosis is associated with a small aortic root. On the Bentall operation, the size of the bioprosthesis is totally dependent on the graft size, which is also determined by the size of the aortic annulus. An Edwards Perimount bioprosthesis (Edwards Lifescience, Irvine, CA) usually requires a 5 mm larger vascular graft size. Therefore, it is difficult to obtain a sufficiently large bioprosthesis especially for patients with a small aortic root. However, the double sewing ring technique with a Valsalva graft can use a larger bioprosthesis because the skirt portion of a Valsalva graft has sufficient room for a larger bioprosthesis. The second sewing ring to the aortic annulus can also fix a small aortic root using a double folded collar portion.
The patient was a 35-year-old female. Her echocardiography revealed severe aortic root stenosis with a 137 mmHg of pressure gradient, which was significantly increased for at least 1 year, and severe aortic valve regurgitation. She wished to have children and a biological Bentall procedure was scheduled. Her height was 158 cm and she weighed 55 kg with a 1.55 m2 body surface area. A 21 mm Edwards Perimount bioprosthesis was selected to obtain a sufficiently effective valvular orifice area and a composite graft was made with a 24 mm Gelweave Valsalva graft. Her aortic root was extremely small and the aortic annulus was incised at the non coronary sinus as Nick's method for its enlargement. But the size of the enlarged aortic annulus was only 19 mm in diameter. Sixteen pieces of 2-0 U sutures were placed around the aortic annulus and a 24 mm Gelweave graft was fixed to this narrow aortic annulus. The cardiac ischemic time was 123 min, and the pump time was 169 min. The operation was done within 5 h without a blood transfusion and the postoperative course was uneventful.
For young women who hope to have children, the Ross procedure is an ideal operation but the biological Bentall procedure is another alternative. However, a larger bioprosthesis is difficult to implant into a small aortic root. The double sewing ring technique reported by Albertini et al. is an excellent technique to allow the implantation of a sufficiently large bioprosthesis for a small aortic root, as seen in a congenital aortic valve stenosis. This is another advantage of this technique in addition to the ease of reimplantation of the valves in the event of a redo surgery.
Footnotes
The authors of the original paper [1] were invited to reply to this Letter to the Editor but their reply was not received.
References
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