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Ann Thorac Surg 2004;78:1479-1481
© 2004 The Society of Thoracic Surgeons

How to do it

Simple Modification of "T. David-V" Valve-Sparing Aortic Root Replacement to Create Graft Pseudosinuses

Philippe Demers, MDa, D. Craig Miller, MDa,*

a Department of Thoracic and Cardiovascular Surgery, Stanford University School of Medicine, Stanford, California, USA

Accepted for publication August 21, 2003.

* Address reprint requests to Dr Miller, Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA, USA 94305-5247
dcm{at}stanford.edu


   Abstract
Top
 Abstract
Introduction
 Technique
 Comment
 Acknowledgments
 References
 
The absence of sinuses of Valsalva is postulated to perturb coronary flow patterns and to create abnormal leaflet stresses, which theoretically may limit the long-term durability of valve-sparing aortic root replacement with the original Tirone David-I reimplantation technique with a cylindrical tube graft. David developed the "T. David-V" procedure in 2001; it creates large billowing Dacron pseudosinuses while retaining the reimplantation concept. To illustrate a simple modification of the T. David-V technique, we describe a patient with Marfan's syndrome who underwent valve-sparing aortic root replacement with 1 large and 1 small graft to create pseudosinuses in the Dacron graft, to facilitate suturing the valve inside the graft, and to make the distal graft-to-aorta anastomosis a better size match.


   Introduction
Top
 Abstract
 Introduction
Technique
 Comment
 Acknowledgments
 References
 
Historically, replacement of the aortic root and aortic valve with a composite valve graft incorporating a mechanical prosthesis has been the standard operation for patients with aortic root pathology and aortic regurgitation [1]. Over the last 10 years, valve-sparing aortic root replacement has become popular in selected patients [2, 3]. Analysis of the results after reimplantation (various versions of the Tirone David procedure) [3, 4] and remodeling (Yacoub procedure and its derivatives) methods [2] indicates that the reimplantation method is more hemostatic, provides more reliable annular stabilization, and might be associated with better long-term durability, eg, less recurrent aortic regurgitation and a lower incidence of reoperation, especially in patients with Marfan's syndrome (MFS) [4, 5]. The Yacoub remodeling procedure has the theoretical advantage of recreating sinuses of Valsalva, which might enhance long-term leaflet durability by decreasing diastolic leaflet closing stresses [6]. Refinement of the David reimplantation procedure to create pseudosinuses [4], the so-called T. David-V technique [7], uses a much larger graft, which is "necked down," or plicated, at the annular and sinotubular junction levels. We describe a simple modification—use of 2 grafts of different sizes—to create large pseudosinuses of Valsalva and facilitate suturing the valve inside the graft, as well as the distal graft-to-aorta anastomosis.


   Technique
Top
 Abstract
 Introduction
 Technique
Comment
 Acknowledgments
 References
 
After inspection and measuring of the valve cusps and sizing of the sinotubular junction, the base of the aortic root is dissected out circumferentially below the level of cusp insertion. The sinuses of Valsalva are excised, the annular size is measured, and the coronary buttons are fashioned. According to the average height of the 3 aortic cusps, the traditional graft diameter (T. David-I) is determined by using David and Feindel's original formula [3]:

d = graft diameter; hleaflet = average height of the leaflets; Aowall = aortic wall thickness. A woven double-velour Hemashield graft (Medi-Tech, Boston Scientific Corp, Natick, MA) 6 to 8 mm larger than the calculated size is necked down proximally with 9 to 10 interrupted 5-0 braided polyester sutures by using a commercial valve sizer as a guide inside the graft. The graft is then implanted by using 12 to 14 braided polyester 2-0 mattress sutures placed in the left ventricular outflow tract in a horizontal plane immediately below the lowest level of the valve leaflets, except at the commissure between the left and right coronary leaflets, where the sutures partially follow the scalloped contour of the ventricular-aortic junction. The valve is reimplanted inside the large graft by using 4-0 polypropylene sutures in a running fashion, starting at each commissure. Because the large graft provides plenty of room, suturing the valve is much easier without bunching or crowding of the aortic tissue. If cusp free margin shortening to correct or prevent prolapse is necessary, it is performed by using a 5-0braided polyester suture placed in the nodulus Aranti. The coronary buttons are anastomosed to their respective neosinuses with 4-0 or 5-0 polypropylene sutures. The large graft is then amputated immediately above the tops of the commissures. The diameter of the distal graft is selected according to the estimated appropriate diameter of the neosinotubular junction [3] and typically approximates the caliber of the normal distal ascending aorta, to which this smaller graft is anastomosed. Because the distal aorta in patients with MFS is usually very small, using this small graft makes the distal anastomosis much easier. Finally, the pseudosinuses are created by sewing the distal end of the large graft to the second smaller graft with a continuous 4-0 polypropylene suture. Alternatively, if total or partial arch replacement is necessary, this is performed initially, and then the distal arch graft is sewn to the large proximal aortic root graft at the sinotubular junction as the last step.

A 25-year-old woman with MFS was referred because of a progressive increase in the size of the aortic root. By transthoracic echocardiography, the aortic root was 5.5 cm in diameter, the distal ascending aorta was 20 mm, the trileaflet aortic valve was functioning normally, and the aortic annulus was mildly dilated. As shown in Figure 1, she underwent valve-sparing aortic root replacement with the modified T. David-V reimplantation technique by using 2 grafts of different sizes (34 mm proximal graft necked down to 25 mm proximally; distal graft 24 mm). Intraoperative postcardiopulmonary bypass transesophageal echocardiography and postoperative transthoracic echocardiography showed a normal aortic annular diameter, normal valve function without any regurgitation, and bulging Dacron (DuPont, Wilmington, DE) pseudosinuses (Fig 2). She recovered uneventfully and was discharged home on postoperative day 5.



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  		Fig 1. Intraoperative picture illustrating a completed valve-sparing aortic root replacement with the modified Tirone David-V technique with a 34-mm graft used proximally (black arrow) and a 24-mm graft distally (white arrow). Note the large proximal graft surrounding the valve and how well the smaller distal graft conforms to the small (normal-sized) distal ascending aorta. The right coronary artery button is visible in the right graft pseudosinus (white arrowhead).

 


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  		Fig 2. Postoperative transthoracic echocardiogram (parasternal long-axis view in early diastole) demonstrating bulging graft pseudosinuses (arrowheads) in the reconstructed aortic root, a normal aortic annular diameter, well-coapting aortic valve cusps, and abrupt graft narrowing at the anastomosis between the proximal and distal grafts, representing the neosinotubular junction (arrows).

 

   Comment
Top
 Abstract
 Introduction
 Technique
 Comment
Acknowledgments
 References
 
Until recently, composite replacement of the aortic valve and ascending aorta by using a composite valve graft was considered the standard operation for aneurysms and dissection involving the aortic root [1]. In carefully selected patients, aortic root replacement with preservation of the native aortic valve, either as a remodeling (Yacoub) or reimplantation (David) procedure, has become an attractive alternative option to avoid anticoagulation and complications inherent to prosthetic valves. The remodeling procedure, pioneered by Sarsam and Yacoub [2], has the theoretical advantage of recreating sinuses of Valsalva in the graft, and this might enhance long-term valve durability by decreasing leaflet stresses [6]. The absence of fixation of the aortic annulus, however, can lead to progressive annular dilatation and recurrent aortic regurgitation, especially in patients with MFS [5, 7]. In these patients, the reimplantation or David technique is associated with less early postoperative bleeding and provides better annular stabilization [4, 5]. A modified David reimplantation procedure [4], which uses a 6- to 8-mm larger graft and suture plication at both the annular end and the neosinotubular junction (the so-called T. David-V technique [7]), combines the advantage of the remodeling technique with firm anchorage of the aortic annulus. Theoretically, creation of pseudosinuses produces more natural leaflet motion, minimizes systolic contact between the valve cusps and the Dacron graft, and reduces diastolic closing cusp stresses, all of which may enhance long-term valve durability [6]. This approach also maintains relatively normal coronary flow patterns. Modifying the fabrication of a tubular graft with customized teardrop-shaped sinuses of individual compliance was devised and tested in vitro by Thubrikar and colleagues [8], and this alternative technique can be applied to either remodeling or reimplantation. Recently, De Paulis and colleagues [9] introduced the Valsalva graft, a modified Dacron conduit that incorporates sinuses of Valsalva (Sulzer Vascutek, Renfrewshire, Scotland). The use of this conduit, however, is hindered by the predetermined height of the sinus portion and fixed diameters of the large and small parts of the graft. In particular, some patients with MFS have aortic valve commissures that are 4.0 cm or taller, which would exceed the height of the sinuses in the Valsalva graft [7].

We report a simple addition to the latest T. David-V technique—using 2 grafts of different sizes—which easily creates graft pseudosinuses of Valsalva, facilitates sewing the valve inside the graft, and makes the distal aortic anastomosis a better size match. This technique also allows secure stabilization of the aortic annulus. Moreover, this simplified approach gives the surgeon unlimited flexibility to create the size of the aortic annulus, the diameter and length of the bulbous graft pseudosinus portion, the diameter of the sinotubular junction, and the diameter of the distal graft segment. Long-term follow-up studies are necessary to assess the durability of this approach and whether it is different from other methods. Its practical and technical advantages, however, have made it our method of choice for valve-sparing aortic root replacement.


Dr Miller discloses that he has a financial relationship with Boston Scientific, Corp.

 


   Acknowledgments
Top
 Abstract
 Introduction
 Technique
 Comment
 Acknowledgments
References
 
Dr Demers is supported by a Research Fellowship Award of the Heart and Stroke Foundation of Canada and is a Thelma and Henry Doelger Cardiovascular Surgical Scholar at Stanford University Medical School.


   References
Top
 Abstract
 Introduction
 Technique
 Comment
 Acknowledgments
 References
 

  1. Yun KL, Miller DC, Fann JI, et al. Composite valve graft versus separate aortic valve and ascending aortic replacement. Is there still a role for the separate procedure? Circulation. 1997;96(Suppl 2):II368–375[Medline]
  2. Sarsam MAI, Yacoub M. Remodeling of the aortic valve annulus. J Thorac Cardiovasc Surg. 1993;105:435–438[Abstract]
  3. David TE, Feindel CM. 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]
  4. David TE, Armstrong S, Ivanov J, Feindel CM, Omran A, Webb G. Results of aortic valve-sparing operations. J Thorac Cardiovasc Surg. 2001;22:39–46
  5. de Oliveira NC, David TE, Ivanov J, et al. Results of surgery for aortic root aneurysm in patients with Marfan syndrome. J Thorac Cardiovasc Surg. 2003;125:789–796[Abstract/Free Full Text]
  6. Leyh RG, Schmidtke C, Sievers HH, Yacoub MH. Opening and closing characteristics of the aortic valve after different types of valve-preserving surgery. Circulation. 1999;100:2153–2160[Abstract/Free Full Text]
  7. Miller DC. Valve-sparing aortic root replacement in patients with the Marfan syndrome. J Thorac Cardiovasc Surg. 2003;125:773–778[Free Full Text]
  8. Thubrikar MJ, Robicsek F, Gong GG, Fowler BL. A new aortic root prosthesis with compliant sinuses for valve-sparing operations. Ann Thorac Surg. 2001;71:S318–322[Abstract/Free Full Text]
  9. De Paulis R, De Matteis GM, Nardi P, Scaffa R, Bassano C, Chiariello L. Analysis of valve motion after the reimplantation type of valve-sparing procedure (David 1) with a new aortic root conduit. Ann Thorac Surg. 2002;74:53–57[Abstract/Free Full Text]



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