Ann Thorac Surg 2001;71:1380-1381
© 2001 The Society of Thoracic Surgeons
How to do it
Commissure holder: an innovative device for aortic valve-sparing technique
Hiroji Akimoto, MDa,
Yusuke Tsuru, MDa,
Hitoshi Yokoyama, MDa,
Mitsuaki Sadahiro, MDa,
Koichi Tabayashi, MDa
a Department of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
Accepted for publication September 6, 2000.
Address reprint requests to Dr Akimoto, Department of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
e-mail: akimoto{at}mail.cc.tohoku.ac.jp
 |
Abstract
|
|---|
The key to obtaining maximal valve coaptation from the aortic valve-sparing procedure is in appreciating the optimal geometry of each component of the aortic root. We describe a new device called the Commissure Holder (patent pending) that aids in the selection of an appropriate graft size and in the determination of the optimal position at which each commissure should be sutured to the graft.
|
Introduction
|
|---|
The diversity of the aortic root geometry sometimes causes difficulty in obtaining coaptation of the aortic valve in valve-sparing operations. Several surgical techniques have been described for determining the appropriate graft size and correcting the dilated sino-tubular junction [1–6]. However, progressive deterioration of postoperative aortic regurgitation has been observed in some patients who underwent the aortic valve-sparing procedure. We believe it is crucial to obtain maximum valve coaptation at the first operation. Therefore, to be able to determine the optimal aortic root geometry of each patient, we have designed what we call the Commissure Holder (patent pending) that facilitates selection of the appropriate graft size and determination of the best sites for positioning the commissures.
|
Technique
|
|---|
After the heart is arrested by administration of the cardioplegic solution, the diseased aortic wall is resected with harvesting of button-shaped regions including the ostia of the left and right coronary arteries. Stay sutures are placed on the top of the valve commissures. (The former procedures are exactly the same as the previous leading technique.) The aortic annular sizing is performed using ball sizers, aiding the initial choice of the Commissure Holder. The same size or smaller size Commissure Holder (one or two millimeters smaller in diameter than the aortic annulus) is chosen because of the relationship between the aortic root and the aortic valve [7]. On the superior circumferential edge of the Commissure Holder, there are slits at intervals of 2 to 3 mm, three of which are marked on an equilateral triangle (Fig 1). Each stay suture is passed through the inside of the Commissure Holder, which can be placed on the aortoventricular groove, as for the Dacron graft in the implantation technique. Because the cylindrical Commissure Holder is made from transparent material, surgeons can see the aortic valvular components from all directions, helping to obtain an accurate image of the optimal relationship of the three cusps before the following procedures are carried out. Each stay suture of the valve commissure is put into the slit that is marked on the Commissure Holder. The position of each commissure that provides maximal coaptation is determined by suspension of each stay suture and by changing the slit in which the stay suture is placed (Fig 2). Filling the device with saline is always helpful to examine the valve coaptation. If the coaptation is unsatisfactory, a different sized Commissure Holder is chosen. The size of the Commissure Holder that provides maximum coaptation is the appropriate size for the graft. The height of each commissure is measured by the scales attached to the wall, and the distance between each commissure is measured. The graft is properly cut and trimmed in accordance with these measurements.
View larger version (38K):
[in this window]
[in a new window]
|
Fig 1. The number on the exterior of each Commissure Holder indicates the inner diameter of the cylinder in millimeters. Selection of a vascular graft of the same size as the Commissure Holder will provide the optimum coaptation.
|
|
View larger version (22K):
[in this window]
[in a new window]
|
Fig 2. Each stay suture of the commissure is put into the slit of the Commissure Holder. For each commissure, the position that affords the maximal coaptation is determined by suspending the stay suture and varying the slit where the stay suture is placed.
|
|
The length of the longitudinal cut of the graft is the same as the commissure height; therefore, in general the lengths of the cuts are different. Furthermore, the position of the cut is determined from the position of each stay suture, rather than from one third of the circumference of the graft. Therefore, the widths of the scallops can also be different.
The graft is anchored to the aortic annulus after stitching sutures of the commissures into the corresponding sites of the graft. Scallops of the graft are sutured to the aortic annulus at the line of the cusps using 4-0 or 5-0 polypropylene with reinforcement by autologous pericardial strips. The coronary ostia are then anastomosed to the graft.
|
Comment
|
|---|
Dilated ascending aorta and aortic annular dilatation can alter the constitutional aortic root geometry. Dilated sinotubular junction causes aortic regurgitation. The aortic valve-sparing technique [1, 2] has been accepted and welcomed by many cardiac surgeons for its avoidance of anticoagulation and the consequent quality of life it provides to patients. However, despite the simple concept of the valve-sparing technique, the modified aortic root sometimes remains regurgitant, eventually requiring reoperation [3, 4]. Because the optimal aortic root geometry of each patient is unique, selection of correct graft size and determination of the positions of the commissures are essential to the successful completion of this technique. Silver and Roberts [8] reported that only 16% of patients with normally functioning aortic valves had three cusps of similar size. This suggests that most patients with a dilated aortic root may have substantially different cusp sizes. When three commissures are fixed at three equidistant positions around the graft, the stress on each cusp after root reconstruction could be altered, possibly causing late deterioration and aortic regurgitation.
The Commissure Holder was drawn up from the concept of achieving the optimum reconstruction of the aortic root by determining the particular root geometry. It aids in selecting the appropriate graft size and indicates the proper site for positioning each commissure.
We have applied these instruments in 8 patients who underwent the valve-sparing technique for aortic root replacement. All patients had no aortic regurgitation, or insignificant aortic regurgitation, postoperatively as assessed by echocardiography. The Commissure Holder is very useful for revealing an individual patient’s aortic root geometry with the aim of obtaining maximal valve coaptation.
|
References
|
|---|
-
Pepper J., Yacoub M. Valve conserving operation for aortic regurgitation. J Card Surg 1997;12(Suppl):151-156.[Medline]
-
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]
-
Yacoub M.H., Gehle P., Chandrasekaran V., Birks E.J., Child A., Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg 1998;115:1080-1090.[Abstract/Free Full Text]
-
Schafers H.-J., Fries R., Langer F., Nikoloudakis N., Graeter T., Grumdmann U. Valve-preserving replacement of the ascending aorta: Remodeling versus reimplantation. J Thorac Cardiovasc Surg 1998;116:990-996.[Abstract/Free Full Text]
-
Cochran R.P., Kunzelman K.S., Eddy A.C., Hofer B.O., Verrier E.D. Modified conduit preparation creates a pseudosinus in an aortic valve-sparing procedure for aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1995;109:1049-1058.
-
Morishita K., Abe T., Fukuda 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]
-
Kunzelman K.S., Grande K.J., David T.E. Aortic root and valve relationships: impact on surgical repair. J Thorac Cardiovasc Surg 1994;107:162-170.[Abstract/Free Full Text]
-
Silver M.A., Roberts W.C. Detailed anatomy of the normally functioning aortic valve in hearts of normal and increased weight. Am J Cardiol 1985;55:454-461.[Medline]
Top
Abstract
Introduction
