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Ann Thorac Surg 2001;72:487-494
© 2001 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, University of Rome, "Tor Vergata", Rome, Italy
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
Presented at the Thirty-seventh Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 29–31, 2001.
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and methodsResultsCommentDiscussionReferences |
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Methods. Echocardiographic studies of the aortic valve dynamics were performed in 14 patients after remodeling of the aortic root (7 standard conduits, group A; 7 new conduits, group B) and in 7 controls (group C). Opening and closing leaflet velocities and percent of slow closing leaflet displacement were measured. Root distensibility and the pressure strain of the elastic modulus were measured at all root levels.
Results. Root distensibility and the pressure strain of the elastic modulus were different in group A and B only at the sinuses (p < 0.001). Opening and closing leaflet velocities were not different among groups. Slow closing leaflet displacement was markedly more evident in group B patients (24.2% ± 1.9% versus 2.5% ± 1.9% in group A, p < 0.001) and similar to controls (22.1% ± 7.9%).
Conclusions. The new conduit guarantees dynamic features of the aortic valve leaflets superior to those obtained with standard conduits and more similar to normal subjects.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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Recently, we employed a new aortic root conduit (Gelweave Valsalva; Sulzer Vascutek, Renfrewshire, Scotland) that allows a better reconstruction of the sinuses of Valsalva without the need of modifying the surgical techniques currently employed. This graft has been used in all types of surgical techniques, commonly used to treat the pathology of the aortic root with good results [6]. The purpose of this study was to compare echocardiographically the aortic root anatomy and aortic valve motion after the remodeling type of valve-sparing procedure using a standard conduit and the new aortic root conduit.
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R x 100)/R, where R indicated the difference between the largest and the smallest diameter and R, the average diameter. Pressure strain elastic modulus (PSEM) was calculated as PSEM = (P x R)/R, where P is the difference between systolic and diastolic pressures. Slow closing displacement (SCD) of leaflet was calculated as SCD = [(D1-D2)/D1]*100, where D1 indicated the maximum leaflet displacement and D2, leaflet displacement before rapid valve closing (Fig 3).
Statistical analysis
A two-way analysis of variance (ANOVA) test was used to compare continuous data among the three groups. Posthoc comparisons were made using the Scheffè F-test. When the variances were not the same for each group (ie, SCD, RVOV, RVCV, ET, VTI, PCR, PSEM) the nonparametric Kruskal-Wallis or Mann-Whitney tests were utilized, as appropriate. Categorical data were compared using the 
2 test. A p value less than 0.05 was considered significant. All statistical analysis was performed with StatView (version 5.0) for Windows 8.0 (SAS Institute Inc, Cary, NC).
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TopFootnotesAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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Comment |
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TopFootnotesAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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Obviously, the great advantages of these techniques resides in the avoidance of anticoagulation with its related morbidity, as well as in the virtual absence of thromboembolism and endocarditis. However, both of these valve-sparing procedures have some theoretic limitations that could endanger the longevity of the spared valve leaflets. In the David and Feindel [4], or reimplantation technique, where the valve is resuspended inside a standard Dacron tube with the advantages of stabilizing the annulus and giving a better support of the aortic wall, the complete lack of sinuses of Valsalva places the leaflet at risk of abrasion against the Dacron wall during systole. Furthermore, the lack of sinuses of Valsalva has been shown to alter the physiologic motion of valve leaflets during the cardiac cycle [5]. In the Yacoub [2, 3], or remodeling type of valve-sparing procedure, where a standard Dacron tube is trimmed into the mirror image of the crown shape of the aortic annulus recreating a space behind the leaflets, the sinuses cannot expand circumferentially in a physiologic manner. Furthermore, because of the lack of annulus support there is a tendency toward progressive aortic insufficiency [14].
The new aortic prosthesis has been designed to recreate more closely the anatomic and physiologic conditions of the natural aortic root without the need for modifying the original techniques. It has been already successfully tested in the reimplantation type of valve-sparing procedure in which recreating new sinuses of Valsalva of normal shape and dimension completely eliminated the major drawback of this technique [6]. However, in this study we wanted to compare the new prosthesis with a standard prosthesis in the setting of the remodeling type of valve-sparing procedure where the differences are more subtle and more sensitive measurements are needed to ascertain if the new design has characteristics that would allow a better reproduction of normal valve physiology.
There are two main reasons why valve leaflets could have a reduced longevity after a valve-sparing operation. The first one depends on the possibility that one or more leaflet could touch the Dacron wall in full systole; in this case the consequent thickening of the leaflet would create the conditions for an early malfunctioning of the valve and probably a sudden leaflet tearing. The second one depends on the ability of the surgical reconstruction to reproduce a normal leaflet motion during the cardiac cycle. Obviously, for a leaflet to fail as the consequence of improper valve opening or closing features will take an amount of time much longer than that due to the consequence of an intermittent contact with the Dacron wall. Nevertheless, mimicking as close as possible a normal leaflet motion would give the patient higher chances of maintaining normal leaflet longevity. A normal valve motion during the cardiac cycle is mainly regulated by the anatomic configuration and by the cyclic modifications of the aortic root. The valve starts to open even before forward blood flow because of a slight increase of the diameter at the level of the commissures. Next, as soon as forward flow opens the leaflets and reaches the sinus ridge, it curls down into the sinuses of Valsalva, acting as a cushion for the leaflets and preventing them from impact with the aortic wall. Then, because of the eddy currents inside the sinuses, the leaflet starts to close before forward flow has ended, with the consequence that once blood flow reverses in diastole, leaflets excursion will be smaller and valve closure will be smooth with minimal stress. Furthermore, cyclic expansion of the sinuses contributes to a reduction of the systolic and diastolic stress on the valve leaflets [15–19].
Leyh and colleagues [5] recently compared the remodeling and the reimplantation types of valve-sparing technique using a standard Dacron graft in two groups of patients. They found that due to the preservation of the shape and independent mobility of the sinuses with the remodeling technique, it was possible to achieve a near-normal valve movement. Conversely, the lack of sinuses in the reimplantation procedure prevented a normal valve motion and in some cases was also responsible for leaflet-wall contact. Our study confirmed in part the good results that can be obtained with the remodeling technique using a standard conduit. On the other hand it also showed that by using the modified conduit some of the physiologic features of the aortic root and leaflets were better preserved. First, sinuses were bigger and more round-shaped in patients receiving the modified conduit. This was confirmed mainly by the larger area beyond the leaflet that was measured in patients receiving the new prosthesis. Second, because of the different orientation of the Dacron corrugations, a circumferential distensibility at the level of the sinuses was reproduced. It is in fact possible that the horizontal orientation of the corrugations in the standard prosthesis might be more prone to lose distensibility with time. Third, as a consequence of a better shape and function of the sinuses, slow closing displacement of the leaflet was significantly more evident and similar to normal in group B patients. In summary, with the modified prosthesis the leaflet could reach a full opening diameter (24.7 mm) that perfectly matched the diameter at the anulus (24.4 mm), and the efficiency of the vortices inside the sinuses guaranteed a significant slow closing displacement of the leaflets and consequently a smooth valve closure. This near-physiologic behavior was maintained even in presence of a short duration of valve opening (average ejection time of 219 ms). By obtaining a more physiologic valve motion, the stress on the leaflets is decreased. Grande-Allen and colleagues [20] using finite element modeling demonstrated that the valve-sparing techniques that allowed sinus space formation resulted in simulated leaflet stress that is closer to normal. More interesting, similarly to our results, they found that a more rounded shape of the root wall is more suitable to share the pressure-induced load with the leaflet than the classic remodeling technique [20]. Finally, very recently Zehr and colleagues [21], using a custom-made Dacron graft similar to ours, demonstrated how it was possible to recreate the natural geometry and function of the aortic root and valve leaflets.
Besides the advantages in term of preservation of normal valve physiology, some practical and technical advantages of the modified prosthesis need to be pointed out. Because of the vertical orientation of the Dacron corrugations, the consequent circumferential expansion of the sinuses, and the presence of a well-defined sinotubular junction, tailoring of the prosthesis appears to be facilitated. As a matter of fact the tongue-shaped extensions need to be tailored just to fit the valve remnant, making easier suturing the graft along the scalloped shape of the anulus. Conversely, with a standard Dacron conduit the three Dacron extensions need to be much longer than the height of the valve remnants (Fig 2). In other words, in order to generate sinuses, more graft length is needed to suture along the crescent shape of the aortic anulus. During suturing the surgeon has to take into account these discrepancies in length, potentially increasing the chance of bleeding and, most important, of a slight distortion of the valve geometry. Therefore, the results will be less consistent and more dependent on the ability of the surgeon to restore a normal anatomy. As a matter of fact the incidence of residual valve insufficiency early after surgery is related to an imperfect root reconstruction. Although the number of patients considered in this study is relatively small, it is already evident a greater incidence of residual valve insufficiency in those patients receiving a standard Dacron graft (5 patients in group A versus 2 patients in group B). Overall, the remodeling technique is considered more technically difficult and less forgiving for small technical inaccuracies. On the other hand, it is possible that the reimplantation technique with the new prosthesis will guarantee more consistent results associated with a reconstruction of the sinuses of Valsalva identical to that obtained with the remodeling technique [6]. A similar study using the reimplantation technique and the modified Dacron graft is now warranted.
Finally, several limitations of this peculiar protocol have been already well outlined in a similar study [5]; in particular, patients receiving the new prosthesis were evaluated at a shorter time interval after surgery compared with patients receiving a standard prosthesis. Nevertheless, patients were well matched regarding their preoperative characteristics and graft dimensions.
In conclusion, compared with a standard conduit, the new prosthesis appears to facilitate the remodeling type of surgical reconstruction of the aortic root anatomy and at the same time it seems to offer potential for a better reproduction of the normal root physiology. We consider it a further step toward an optimal preservation of the leaflet longevity.
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TopFootnotesAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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Discussion |
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TopFootnotesAbstractIntroductionPatients and methodsResultsCommentDiscussionReferences |
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Now we are using a modification of our graft which has three bulging individual sinuses which are custom tailored to the patients anatomy. We have tested it extensively both in vitro and clinically and found that this graft significantly enhanced physiologic leaflet function and decreased leaflet-stress overload. We intend to continue our studies in ascending prosthetic design especially on the subject of the wall-compliance.
DR ARTHUR J. CRUMBLEY III (Charleston, SC): Do you have any data about the durability of this technique? It seems to me that tissue ingrowth would limit the duration of any distensibility that one would enjoy initially.
DR DE PAULIS: Yes, thank you for the question. Of course these are preliminary data. You have seen that the patients with the new prosthesis were evaluated only two months after surgery, so it was a significantly shorter time than the other group. So it is possible that we are going to lose that 5% compliance. I am not sure, but it is possible. I hope that having a rounded and deeper shape in the sinuses will still maintain normal valve motion. But of course we will see in the near future, since the first prosthesis was implanted about one year ago.
DR FRIEDRICH MOHR (Leipzig, Germany): I would like to congratulate the authors, too, and I have to admit I have some early experience, thanks to the inventor, with this technique, and I am surprised how well this technique has been applied in our own hospital too.
Doing it myself during the last few weeks I do have a little concern, and I would like to have your thoughts on it. It very nicely reflects the width of the sinuses, which is extended. The concern I had during my last operation is the height of the sinuses. This may be different in various patients. It can occur when using this technique, you will find a low height of the sinuses, and you will have to fix the upper part of the commissures inside the extended sinuses, thus extending the sinotubular junction above the diameter of the annulus. That may be a reason for an increased aortic insufficiency later on. Did you reflect that?
DR DE PAULIS: You are probably referring to the reimplantation or the David 1 procedure, because in that case the thing to do to avoid that problem is to measure the height of the valve remnants against the skirt of the prosthesis before starting the operation. So in case the height of the valve remnants are shorter than the skirt of the conduit, you start the first stitches a little higher in the skirt. So you are sure that you will reach the sinotubular junction, because it is a "must" in this operation to put the top of the commissure at the sinotubular junction. If they are shorter, that is seldom the case, because especially in the Marfan patient they are very long, you have to start a little higher in the skirt. And another thing you can do is just to leave extra aortic wall at the top of the commissures. In this way, you make them longer so you can bring them higher. They always have to reach the new sinotubular junction, that is, the suture where the direction of the corrugations change.
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