Ann Thorac Surg 2001;71:1375-1376
© 2001 The Society of Thoracic Surgeons
How to do it
Bentall procedure with a stentless valve and a new aortic root prosthesis
Ruggero De Paulis, MDa,
Paolo Nardi, MDa,
Giovanni Maria De Matteis, MDa,
Patrizio Polisca, MDa,
Luigi Chiariello, MDa
a Cattedra di Cardiochirurgia, Università di Roma Tor Vergata, Rome, Italy
Accepted for publication November 14, 2000.
Address reprint requests to Dr De Paulis, Cattedra di Cardiochirurgia, Università di Roma Tor Vergata, European Hospital, via Portuense 700, 00149 Rome, Italy
e-mail: depauli{at}tin.it
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Abstract
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We describe a technique to replace the aortic root by means of a stentless valve and a new aortic root Dacron graft (Gelweave Valsalva, Sulzer Vascutek, Renfrewshire, Scotland) that allows an anatomical reconstruction of the sinuses of Valsalva.
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Introduction
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An aortic root replacement in the presence of a diseased aortic valve is usually accomplished by using a composite graft either with a mechanical or biological valve after the technique described by Bentall and De Bono [1] in their classic article. Recently P. Urbanski [2] proposed the use of a composite graft with a stentless porcine valve to combine the strength of a Dacron vascular prosthesis with the hemodynamic advantages of a stentless aortic xenograft. Although the concept is appealing, having a stentless prosthesis in a straight tube will cause the leaflets to impact the aortic wall subjecting them to potential damage. Although similar to the David I valve sparing procedure, in this case the leaflets are fixed in glutaraldehyde and therefore, are more likely to fail under stress.
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Technique
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Recently, in all types of reconstruction of the aortic root, we have been using a specifically designed aortic root prosthesis (Gelweave Valsalva, Sulzer Vascutek, Renfrewshire, Scotland) that allows an anatomical reconstruction of the aortic root when it is implanted [3]. Briefly, this new graft is obtained by attaching to a standard Dacron tube, a small portion of the same Dacron tube with corrugations at 90° with regard to the rest of the graft (the skirt and its height being equal to the diameter of the graft). Then another tract of a standard Dacron tube of the same dimension is attached at the end of the skirt (collar) (see Fig 1). This new Dacron graft, used in conjunction with a stentless valve, prevents that the prosthetic leaflets touch the Dacron during systole.
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Fig 1. Schematic drawing of the new aortic root conduit. It consists of a standard Dacron tube that is attached to a lower section (skirt) of a Dacron tube that expands circumferentially. The collar offers a tubular portion for proper suturing of the valve prosthesis and the patient’s annulus. The prosthetic sinotubular junction maintains a proper placement of the prosthetic valve posts, as well as a cylindrical shape of the prosthetic valve. Once the upper rim of the stentless valve prosthesis is sutured to the vascular prosthesis and the aorta is pressurized, the skirt will bulge to create three pseudosinuses. (ST junction = sinotubular junction.)
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After the aortic valve is excised and the coronary buttons are prepared, a stentless valve (Toronto SPV; St Jude Medical Inc, St Paul, MN) is selected to match the patient’s annulus. Then a new Dacron graft (Gelweave Valsalva, Sulzer Vascutek, Renfrewshire, Scotland) (Fig 1) is selected one size smaller (eg, a 26 mm graft for a 27 mm SPV valve). In this way the valve prosthesis fits snugly into the Dacron graft and the top of the commissures reach the level of the new sinotubular junction. The collar of the Dacron conduit is trimmed to a minimum and the valve and graft are sutured together to the aortic annulus with interrupted 2-0 sutures. Alternatively, the collar is everted and after sewing the valve and tube together, it is used to suture the tube to the valve annulus. This modification allows later removal of a failed valve without touching the proximal suture line as also indicated by Urbanski [4]. The upper rim of the valve is sutured to the vascular prosthesis with a continuous mattress 5-0 polypropylene suture. Care must be taken in assuring that the top of the commissures, properly spaced, are sutured at the level of the new sinotubular junction (Fig 1) or a few millimeters above. After the graft is fenestrated with electrocautery, the coronary buttons are reimplanted in the usual fashion. Anastomosis with the ascending aorta completes the procedure.
Because the valve is fixed to a tubular portion proximally (the collar of the prosthesis and the aortic annulus) and to a tubular portion distally (the new sinotubular junction), it will be perfectly cylindrical. After the aorta has been pressurized, the new Dacron graft will bulge only at the site where the sinus tissue of the patient has been excised (Fig 2). Transesophageal echocardiography shows how the new pseudosinuses prevent the prosthetic leaflets from impacting the Dacron wall. (Fig 3).
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Fig 2. Postoperative angiographic view of the completed surgical procedure showing a competent prosthetic valve and the creation of pseudosinuses.
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Fig 3. Transoesophageal echocardiographic long axis view during systole showing the space (sinus) between the prosthetic leaflets and the prosthetic aortic wall. (Ao = aorta; LV = left ventricle.)
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We have successfully performed this technique in 4 consecutive patients and follow-up echocardiographs after a mean time of 4 ± 2 months have confirmed normal motion of the prosthetic leaflets and the complete absence of valve regurgitation. The patients were discharged on anticoagulant therapy for the first 3 postoperative months only.
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Comment
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Compared to stented bioprostheses the use of a stentless valve in combination with a standard Dacron tube allows a larger valve orifice area and probably a decrease in the risk of prosthetic endocarditis. However, valve durability that is supposed to be prolonged in stentless valve prostheses, is negatively influenced by the lack of sinuses of Valsalva as well as by the lack of compliance of the Dacron conduit. The high stress on the leaflets that is present with a standard straight Dacron conduit might accelerate degeneration of the leaflets exposing them to an early risk of rupture. The use of the new aortic Dacron graft, already successfully employed in aortic valve sparing procedures [3], allows the reconstitution of rounded-shape aortic sinuses. The presence of pseudosinuses and of a well defined new sinotubular junction assures the formation of eddy currents that are of paramount importance for the proper opening and closing mechanism of the aortic leaflets. The use of the new Dacron conduit, without substantial modification of the original technique, assures an anatomical reconstruction of the aortic root with better chance of longer preservation of the prosthetic aortic leaflets.
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Footnotes
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Ruggero De Paulis has a patent licensing agreement with Sulzer Vascutek, Ltd.
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References
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Bentall H., De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
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Urbanski P.P. Replacement of the ascending aorta and aortic valve with a valved stentless composite graft. Ann Thorac Surg 1999;67:1501-1502.[Abstract/Free Full Text]
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De Paulis R., De Matteis G.M., Nardi P., Scaffa R., Colella D., Chiariello L. A new aortic Dacron conduit for surgical treatment of aortic root pathology. Ital Heart J 2000;1:457-463.[Medline]
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Urbanski P.P. Stentless valved composite graft for Bentall operation. Ann Thorac Surg 1999;68:2383-2384.[Free Full Text]
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Abstract
Introduction
