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Ann Thorac Surg 2002;73:694
© 2002 The Society of Thoracic Surgeons

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Correspondence

Dilated aortic root and stentless valve implantation

^a HerzZentrum Hirslanden, Witellikerstrasse 36, CH-8008 Zürich, Switzerland

e-mail: siebenmann{at}herzzentrum.ch

To the Editor

I read with interest the article by Massetti and associates [1], presenting a method to implant a stentless aortic valve in patients with a dilated aortic root. The authors propose to replace the ascending aorta with a Dacron graft of a slightly larger dimension than the aortic annulus. The aorta is transsected 1 cm above the sinotubular junction. The proximal end of the prothesis overlaps the sinotubular junction, while the proximal anastomosis lays inside of the graft. The overlapping "cuff" reduces and maintains the diameter of the sinotubular junction and should therefore prevent central regurgitation of the stentless valve prothesis.

To avoid the risk of central regurgitation, the most important point is the appropriate relationship between the diameter of the sinotubular junction and the size of the prosthesis [2]. A severely dilated sinotubular junction leads to an inappropriate position of the valve commissures and to central regurgitation. In 1997, we introduced a technique to implant a stentless porcine bioprosthesis in the dilated ascending aorta [3] by tailoring the dilated aortic root to a normal dimension using a T-shaped incision, and reinforcing it by wrapping a polyester net around the ascending aorta. In contrast to the method proposed by Dr Massetti and colleagues, the excessive tissue of the aortic root is excised. The transverse incision is placed at a more proximal level close to the origin of the right coronary artery. Thus, the sinotubular junction can be trimmed exactly to the desired dimension. Furthermore, our method avoids replacement of the ascending aorta, which may be favorable particularly in elderly patients.

The recently published method certainly is easier to perform. To choose a Dacron graft in relation to the size of the prothesis is a standardized procedure and probably less hazardous than trimming the aortic root to the desired dimension. However, it should be noted that the sinotubular junction is supported externally by the overlapping part of the graft, which remains unattached to the aortic wall and is at risk of distal migration with time. It therefore could fail to prevent further dilatation of the sinotubular junction.

Between 1996 and 2000, we performed our type of operation in 6 patients. To date, no valve-related complication has occurred, nor has any sign of dilatation of the aortic root or progressive aortic regurgitation.

References

1. Massetti M., Bruno P., Babatasi G., et al. Aortic root remodeling with the "cuff" technique for stentless valve implantation. Ann Thorac Surg 2001;71:1053-1055.[Abstract/Free Full Text]
2. David T.E., Feindel C.M., Bos J., Sun Z., Scully H.E., Rakowski H. Aortic valve replacement with a stentless porcine aortic valve. J Thorac Cardiovasc Surg 1994;106:1030-1036.
3. Siebenmann R.P. Implantation of the Toronto SPV stentless porcine valve in dilated ascending aorta. Ann Thorac Surg 1997;64:1197-1200.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Robert P. Siebenmann Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Siebenmann, R. P. Search for Related Content PubMed Articles by Siebenmann, R. P. Related Collections Valve disease Related Article