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Ann Thorac Surg 2003;76:1751-1753
© 2003 The Society of Thoracic Surgeons

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How to do it

Sizing for modified david’s reimplantation procedure

^a Department of Thoracic and Cardiovascular Surgery, Center for Aortic Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Accepted for publication February 14, 2003.

^* Address reprint requests to Dr Svensson, Center for Aortic Surgery, Marfan Syndrome and Connective Tissue Disorders Clinic, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk F25, Cleveland, OH, USA 44195
e-mail: svenssl{at}ccf.org

	Abstract

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The problem of sizing the graft, annulus, and left ventricular outflow tract for the David reimplantation type of aortic valve preserving procedure remains a concern, particularly in patients with Marfan syndrome. To resolve this issue, a modified method used in over 20 patients is described of doing the repair around a Hegar’s dilator. In essence, the size chosen is according to the patient’s normalized annular size based on body surface area. This technique also creates a neosinus in the root.

	Introduction

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David and Feindel [1] described the technique of mobilizing the aortic valve and the left ventricular outflow tract and then inserting the valve within a tube graft to preserve the aortic valve in patients undergoing aortic root and ascending aortic aneurysm repairs. The David aortic valve reimplantation procedure for preserving the aortic valve has been found to be durable on midterm follow-up, including in those patients with Marfan syndrome [1, 2]. The difficulty however, has been to choose the correct-sized polyester tube graft for inserting the aortic valve into. Suggestions for sizing, based on the estimated length of the leaflets free margins and the predicted size at the sinotubular ridge, have been difficult to implement.

Thus, a method is described here whereby the patient’s expected normal left ventricular outflow tract size is used for choosing a Hegar’s dilator of the equivalent size and then tying the graft around the dilator. The left ventricular outflow tract and annular size is based on the patient’s calculated body surface area.

	Technique

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The technique used for the David reimplantation procedure is similar to that previously described by David (Figs 1–3) [1, 2]. The aorta is opened and the aortic valve mobilized by cutting the aorta between the valve annulus and the coronary arteries in the two coronary sinuses, and, in the noncoronary sinus, cutting along the annulus, leaving a sufficient margin for sewing the valve into the tube graft. Nine or 10 pledgeted sutures are usually placed in the left ventricular outflow tract from inside to the outside (Fig 1), although the illustration shows more than necessary in most patients.

View larger version (62K): [in this window] [in a new window]   Fig 1. Mobilized left ventricular outflow tract and aortic valve with pledgeted sutures being passed from the left ventricular outflow tract and through the aortic graft. Note the graft is beveled for the septum.

View larger version (33K): [in this window] [in a new window]   Fig 2. Tying the sutures around the Hegar’s dilator.

View larger version (43K): [in this window] [in a new window]   Fig 3. Completed repair with neosinus and neosinotubular ridge.

For most men a 28- or 30-mm diameter collagen-coated polyester graft is used for the aortic replacement while, for women, a 26- or 28-mm graft is usually required. The left ventricular outflow tract sutures are then passed through the polyester graft after the proximal end has been beveled for the ventricular septum. Next, the Hegar’s dilator is then placed in the left ventricular outflow through the aortic valve and the sutures are then tied down around the Hegar’s dilator (Fig 2). This technique has the effect of crimping the proximal polyester graft down to the appropriate size and at the same time a new neosinus is created above the left ventricular outflow tract where the polyester graft is typically 7 to 9 mm larger.

Next, the aortic valve is sewn into position within the polyester graft in the usual manner except the anchoring sutures at the top of the commissures are placed approximately 4 mm apart, thus, also crimping and narrowing the graft at the neosinotubular junction (Fig 3). As long as the graft segment above the neosinotubular ridge is not too long, sewing the valve into place is not restricted. The valve is tested by infusing cardioplegia under pressure into the cross-clamped graft. Generous openings are made for the coronary ostia to allow for some elasticity in the neosinus and in case of reoperation. Once the coronary arteries have been reattached to the neosinuses, the repair is usually completed with a separate tube graft between the ascending aorta graft and aortic arch (Figs 1–3).

	Comment

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The modified technique for doing the David reimplantation procedure is a useful method of ensuring both that the valve is competent and that aortic valve stenosis does not occur. We have found the David reimplantation procedure to be particular useful in patients with Marfan syndrome, as David has described [1, 2], and also for patients with 3 or 4+ aortic valve regurgitation. Often in these latter patients the leaflets also need to be repaired or the interleaflet angle at the commissures needs to be narrowed.

For those patients, in whom the aortic valve regurgitation is not severe or who have a bicuspid aortic valve, and who do not have Marfan syndrome, we prefer aortic valve remodeling operations. Initially we used the techniques described by David [1, 2] for remodeling, and also by Yacoub [3], but more recently a technique we [4] have described. With careful selection of valve-preserving techniques in 99 patients in conjunction with ascending aorta or aortic arch repairs, we needed to reoperate on 2 remodeling patients because of aortic valve regurgitation, although our follow-up was relatively short. One patient died after surgery (1.0%).

While good early results can be obtained with appropriate valve repair and remodeling or reimplantation operations, late follow-up will be required. Because patients’ ventricles that are hypertrophied or dilated will likely remodel after surgery, the effect of normalizing the left ventricular outflow tract and annulus will need to be followed. The benefits for the patients are that they do not usually require blood thinners and the risk of stroke or endocarditis may also be less in a patient with a native valve as compared with a prosthetic valve [4].

In conclusion, one of the main advantages of this modified David approach is that reimplantation of the valve is more reproducible, particularly because we believe that the left ventricular outflow tract in patients with aneurysmal dilatation of the root is abnormal. Also, reducing the size is a important element in ensuring valve competence, apart from bringing the commissures back into normal alignment and reducing the interleaflet commissure angle. The left ventricular outflow tract is a critical component in repairing and establishing a functioning valve. By crimping and pleating the graft down to a Hegar’s dilator size, the neosinuses of Valsalva that are created probably aid in the normal valvular function and may also reduce the risk of wear and tear on the leaflets in the long term. This neosinus allows for blood to circulate within the sinuses and aid in coaptation of the leaflets during diastole. Creation of a neosinotubular ridge may also further assist in establishing aortic valve competence. Using this technique, we have not had a patient with more than 1+ aortic valve regurgitation in over 20 patients.

	References

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1. David T.E., Feindel C.M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617-621.[Abstract]
2. Tambeur L., David T.E., Unger M., Armstrong S., Ivanov J., Webb G. Results of surgery for aortic root aneurysm in patients with Marfan syndrome. Eur J Cardiothorac Surg 2000;17:415-419.[Abstract/Free Full Text]
3. 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 2001;121:1220-1221.[Free Full Text]
4. Svensson L.G., Longoria J., Kimmel W.A., Nadolny E. Management of aortic valve disease during aortic surgery. Ann Thorac Surg 2000;69:778-784.[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): Lars G. Svensson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Svensson, L. G. Search for Related Content PubMed PubMed Citation Articles by Svensson, L. G. Related Collections Great vessels