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Ann Thorac Surg 2004;78:385-386
© 2004 The Society of Thoracic Surgeons
Cardiac Surgical Division, Massachusetts General Hospital, Warren 735 55 Fruit St, Boston, MA 02114, USA
e-mail: ahilgenberg{at}partners.org
To the Editor:
The stentless porcine-valved composite conduit of Urbanski and associates [1] must be difficult to construct, as documented in their recent study. An entire paragraph and a three-part illustration point out the critical need to size the valve and graft so as to avoid wrinkles and kinks. An annular suture line is placed and then a scalloped supraannular suture line is needed to implant the stentless valve within the graft, which is only 1 or 2 mm larger than the valve.
The great advantage of our technique of assembling a composite prosthesis from a stented pericardial valve and a Dacron graft is simplicity [2]. The surgeon determines the valve size with the standard sizer and selects the graft size by adding 5 mm. Then with one quick running suture line, the end of the graft and the valve sewing ring are approximated. There is no worry about wrinkles or kinks, no additional scalloped suture line, and no concern about contact of valve cusps with the graft. Because the composite graft is constructed during the aortic cross-clamp time, simplicity is particularly desirable.
Regarding the issue of reoperation, we recommend our composite prosthesis for patients who are more than 65 years old. In such patients, it is likely that the risk of reoperation for structural valvular deterioration will be similar to that for isolated aortic valve replacement with the stented pericardial valve. It is estimated that the risk is 10% over the life of such patients [3]. In younger patients who receive our composite prosthesis with the expectation of a future reoperation, we close the pericardium at the first operation to facilitate safe reentry into the chest. At reoperation, we open the graft transversely just above the coronary implant sites and divide the graft completely if necessary. In some patients, the valve can be excised and replaced within the aortic root graft by placing sutures with pledgets below the aortic annulus, through the Dacron graft, and then through the sewing ring of the new valve. If this is not readily accomplished, the coronary arteries are detached, and the root is re-replaced. None of our patients with a pericardial valve conduit have needed reoperation to date. Four of our older stented porcine valve conduits have been replaced because of late tissue failure; there were no deaths.
Dr Urbanski suggests the possibility of repairing the root aneurysm by the techniques of Sarsam and Yacoub [4] or David and co-workers [5] and then replacing the aortic valve inside the graft. The former technique would be a poor choice in this situation because of the risk of late dilatation of the aorta remaining beneath the valve commissures and concern about increased bleeding risk with the long suture lines in fragile aortic tissue in the sinus regions. Placement of the Dacron graft according to the latter reimplantation technique, followed by aortic valve replacement into the annulus inside the graft, is a possibility that could avoid the two problems already mentioned. Whether this technique would "simplify" a reoperation for late tissue failure of the valve is uncertain.
The technique that we described is simple, safe, effective, and durable. Its main use is in older patients with small risk of reoperation. In our experience, reoperation can be conducted with low risk without modifying our recommended strategy of a simple conduit made from a stented pericardial valve and a Dacron graft.
References
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