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Ann Thorac Surg 1999;67:599
© 1999 The Society of Thoracic Surgeons

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Correspondence

A surgical method for selecting appropriate size of graft in aortic root remodeling

^a The International Heart Institute of Montana Foundation, 554 West Broad Way Ave, Missoula, MT 59802 USA

e-mail: duran{at}montana.com

We read with great interest the article by Morishita and colleagues [1] on appropriate graft sizing in aortic root remodeling. The difficulty in selecting the "appropriate" graft conduit size in valve-sparing root replacement procedures is due to several features unique to the aortic root, the most important of which is that the aortic root is a dynamic structure with variable elasticity and compliance. The aortic root distends with pressure in a nonlinear fashion, making estimations of the in vivo aortic root dimensions based on measurements obtained from the flaccid heart extremely difficult. Hansen and associates [2] demonstrated a 25% difference in radial distensibility of the static aortic wall between pressures of 0 and 120 mm Hg. Such studies point to the potential for a significant size mismatch that may occur between the native aortic root and the graft conduit using current methods. Attention should also be drawn to the authors’ contention that "each commissure (of the aortic valve) corresponds to an apex of an equilateral triangle." Past studies have shown that the intercommissural distance of the left coronary sinus is clearly smaller than either that of the right or the noncoronary sinuses [3]. We have also made similar corroborating anatomic observations (unpublished observations).

Should the aortic valve be competent, a more reliable method is the measurement by transesophageal two-dimensional echocardiography of the aortic valve diameter at its base, which was shown in vitro by Swanson and Clark [4] to undergo fewer dimensional changes during the cardiac cycle. Our own work with sonometric crystals placed in the aortic root of sheep showed that although the area at the level of the commissures expanded 35%, the area at the base only changed 5% (unpublished observations). When aortic valve regurgitation is present, the length of the free edge of the smallest leaflet should be used, keeping in mind that this length is longer than the valve diameter. It is interesting that 500 years after the seminal work of Leonardo da Vinci, we still lack a precise knowledge of the elusive aortic root.

References

1. Morishita M., Abe T., Fukada J., Sato H., Shiiku C. A surgical method for selecting appropriate size of graft in aortic root remodeling. Ann Thorac Surg 1998;65:1795-1796.[Abstract/Free Full Text]
2. Hansen B., Menkis A.H., Vesely I. Longitudinal and radial distensibility of the porcine aortic root. Ann Thorac Surg 1995;60:S384-S390.
3. Volleberg F.E.M.G., Becker A.E. Minor congenital variation of cusp size in tricuspid aortic valves: possible links with isolated aortic stenosis. Br Heart J 1977;39:1006-1011.[Abstract/Free Full Text]
4. Swanson W.M., Clark R.E. Dimensions and geometric relationships of the human aortic valve as a function of pressure. Circ Res 1974;35:871-882.[Abstract/Free Full Text]

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This Article 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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Suk Jung Choo Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Choo, S. J. Articles by Duran, C. M.G. Search for Related Content PubMed Articles by Choo, S. J. Articles by Duran, C. M.G. Related Collections Related Article