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Ann Thorac Surg 1998;65:1795-1796
© 1998 The Society of Thoracic Surgeons

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How to Do It

A Surgical Method for Selecting Appropriate Size of Graft in Aortic Root Remodeling

^a Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan

Accepted for publication December 8, 1997.

Address reprint requests to Dr Morishita, Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Japan 060

	Abstract

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We describe a surgical technique for selecting the appropriate size of a tube graft in aortic root remodeling procedures. As the technique has a geometric basis, we believe that our method is more accurate in determining the graft size than others.

	Introduction

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There is considerable interest in aortic valve-sparing techniques to treat patients with aortic root aneurysm. The key to sparing the aortic valve is correction of the dilated sinotubular junction with a tube graft. Therefore, it is crucial to determine the appropriate size of the tube graft [1]. This brief report describes our technique for selecting a graft with the correct size.

	Technique

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After extracorporeal circulation is established in the standard fashion and the aorta is cross-clamped, cold blood cardioplegia is delivered retrogradely into the coronary sinus. The ascending aorta is transected a few millimeters above the commissures. The left and right coronary ostia are harvested in the shape of a button. Stay sutures are placed at the three commissures. We produce optimum coaptation of the aortic valvular leaflets by using forceps. With the aortic valvular leaflets coadjusted centrally (Fig 1), the stay sutures are pulled up in a vertical direction and the lengths from one commissure to the others are measured and averaged (Fig 2). Considering each commissure corresponds to an apex of an equilateral triangle, the triangle is circumscribed by a ring at the sinotubular junction (Fig 3). Thus the diameter of the sinotubular junction is defined geometrically as follows: , where SD is the diameter of the sinotubular junction and CD is the average length between two commissures. According to this equation, we have chosen a graft 15% larger than the average distance between two commissures. After we determine the diameter of the sinotubular junction, the remaining aortic sinuses are excised, leaving an arterial remnant 3 or 4 mm high above the aortic annulus. Subsequent procedures are carried out following the technique reported by David and associates [2].

View larger version (47K): [in this window] [in a new window]   Fig 1. Coaptation of the aortic valvular leaflets.

View larger version (136K): [in this window] [in a new window]   Fig 2. Measurement of the distance between two commissures.

View larger version (54K): [in this window] [in a new window]   Fig 3. Geometric relationship.

	Comment

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Another important point is that the competence of the valve should be restored before the intercommissural distances are measured. Pepper and Yacoub [1] achieve this by stretching the three commissures in a vertical direction with stay sutures while observing the position of the cusps. Our method is a little different from theirs. The stay sutures are pulled up in a vertical direction while optimum coaptation of the cusps is produced with forceps as illustrated in Figure 1. This method seems easier to us.

We have used this technique to choose the appropriate size of graft in our last 4 patients, and postoperative echocardiographic study demonstrated that no patient had more than mild aortic regurgitation. These experiences, although limited, confirm our belief that this method is accurate because of its geometric foundation.

	References

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1. Pepper J., Yacoub M. Valve conserving operation for aortic regurgitation. J Card Surg 1997;12(Suppl):151-156.[Medline]
2. David T.E., Feindel C.M., Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm. J Thorac Cardiovasc Surg 1995;109:345-352.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kiyofumi Morishita Tomio Abe Hiroki Sato Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Morishita, K. Articles by Shiiku, C. Search for Related Content PubMed PubMed Citation Articles by Morishita, K. Articles by Shiiku, C.