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Ann Thorac Surg 1999;67:1501-1502
© 1999 The Society of Thoracic Surgeons

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How To Do It

Replacement of the ascending aorta and aortic valve with a valved stentless composite graft

^a Herz- und Gefäß-Klinik, Bad Neustadt, Germany

Accepted for publication November 24, 1998.

Address reprint requests to Dr Urbanski, Herz- und Gefäß-Klinik, Salzburger Leite 1, 97616 Bad Neustadt, Germany

	Abstract

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A technique of total aortic root replacement with a stentless porcine composite graft is described. This graft is assembled during surgery using a woven polyester vascular prosthesis and a stentless aortic bioprosthesis.

	Introduction

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Total aortic root replacement with a valved mechanical composite graft as described by Bentall and De Bono is regarded as a routine surgical method [1–4]. The alternative use of aortic allografts is limited by their availability. Xenografts are rarely chosen, although especially older patients might benefit from biological materials [2–5]. A composite graft with a stentless porcine valve combines the benefits of the strength and stability of a woven polyester (Dacron) vascular prosthesis commonly used for replacement of the thoracic aorta, and the hemodynamic characteristics of a stentless aortic xenograft, which are similar to those of a aortic homograft [6–8].

Cardiopulmonary bypass is initiated with an arterial cannula in the ascending aorta, the transverse arch, or the femoral artery, depending upon the extent of the aneurysm. After the institution of cardiopulmonary bypass, the ascending aorta is cross-clamped and the heart is arrested with cold crystalloid cardioplegia.

The ascending aorta and the aortic valve are excised. The coronary ostia are excised in the form of Carrel patches (buttons). The annulus is measured and a stentless, porcine valve (SPV Toronto; St. Jude Medical, Inc, St. Paul, MN) of corresponding size is selected. The matching vascular prosthesis of collagen-coated woven polyester (InterGard; InterVascular, La Ciotat, France) should be one size smaller than the valve prosthesis. For example, when the valve size is 25, a tube graft with a diameter of 24 mm is used.

The xenograft is placed inside the vascular prosthesis and secured at three points, corresponding to the commissures with single 5-0 polypropylene sutures (Fig 1). The composite graft is then sewn to the aortic annulus with a continuous 4-0 polypropylene suture by grasping both the vascular tube and the cuff of the prosthetic valve. The upper rim of the valve is then sutured to the vascular prosthesis with a continuous, mattress 5-0 polypropylene suture. The graft is fenestrated using an electric cauter, and the coronary artery buttons are reimplanted into the graft with continuous 6-0 polypropylene sutures.

View larger version (81K): [in this window] [in a new window]   Fig 1. The aortic stentless valve is placed inside the vascular prosthesis and sucured at three points (A–C). The continuous mattress suture of the upper rim of the valve is indicated (dotted line).

	Comment

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We have seen problems at the site of the suture line between xenograft and vascular prostheses when the aortic root is replaced with a stentless xenograft in a mini-root technique and the ascending aorta with a vascular prosthesis. The technique described in this paper reduces the risk of such problems because the composite graft is long enough for an anastomosis with the aortic arch. An advantage over stented bioprostheses within a composite graft will become obvious in case of a reoperation, where due to the lack of a bulky sewing ring only the valve cusps need to be resected, leaving the tube graft untouched.

We have successfully performed this technique in 5 patients and feel that it provides an attractive alternative for patients with a contraindication for anticoagulation. We continue to follow these patients and plan to provide clinical results as they become available.

	References

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1. Bentall H., De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
2. Borst H.G., Heinemann M.K., Stone C.D. Proximal aortic dissection. In: Borst H.G., Heinemann M.K., Stone C.D., eds. Surgical treatment of aortic dissection. New York: Churchill Livingstone, 1996:123-202.
3. Mingke D., Dresler C., Stone C.D., Borst H.G. Composite graft replacement of the aortic root in 335 patients with aneurysm or dissection. Thorac Cardiovasc Surg 1998;46:12-19.[Medline]
4. Kouchoukos N.T., Wareing T.H., Murphy S.F., Perrillo J.B. Sixteen-year experience with aortic root replacement: results of 172 operations. Ann Surg 1991;214:308-318.[Medline]
5. Mykén P.S., Caidahl K., Larsson P., Larsson S., Wallentin I., Berggren H.E. Mechanical versus biological valve prosthesis: a ten-year comparison regarding function and quality of live. Ann Thorac Surg 1995;60(Suppl 2):S447-S452.
6. Westaby S., Parry A., Giannopoulos N., Pillai R. Replacement of the thoracic aorta with collagen-impregnated woven Dacron grafts. J Thorac Cardiovasc Surg 1993;106:427-433.[Abstract]
7. Franke U., Jurmann M.J., Uthoff K., et al. In vivo morphology of woven, collagen-sealed dacron prostheses in the thoracic aorta. Ann Thorac Surg 1997;64:1096-1098.[Abstract/Free Full Text]
8. Westaby S., Huysmans H.A., David T.E. Stentless aortic bioprostheses: compelling data from the second international symposium. Ann Thorac Surg 1998;65:235-240.[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): Paul P. Urbanski Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Urbanski, P. P. Search for Related Content PubMed PubMed Citation Articles by Urbanski, P. P.