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Ann Thorac Surg 2004;78:2215-2216
© 2004 The Society of Thoracic Surgeons

Correspondence

Annulus Sizing in Aortic Remodeling Procedure

Raymond Cartier, MD, Miguel Chaput, MD

Department of Surgery, Montreal Heart Institute, 5000 Belanger St E, Montreal, PQ H1T 1C8, Canada

rc2910{at}aol.com

To the Editor:

We read with interest the article by Svensson on aortic "sizing" during David's reimplantation procedure [1].

In the last 2 years, it has been our practice to use Hegar's dilators to fix the aortic annulus surface to avoid undersizing the annulus during aortic remodeling, but we index the annulus diameter to patient body surface area (BSA) using larger values. We established a table according to the Human Heart Valve Diameters charts provided by CryoLife as a guide for aortic and pulmonary homograft sizing. These charts were based on Hegar's dilator measurements of 3,161 donated hearts. The BSA was established according to the formula of Haycock and colleagues [2]: .

On the basis of these data, the ideal effective orifice area of the aortic annulus for a specific BSA in men and women is shown in Table 1. In men, it ranges from 1.95 to 2.2 cm2/m2 and in women, from 1.7 to 2.12 cm2/m2. Men with a BSA of 1.5 m2 should have an aortic diameter of around 20 mm; a BSA of 2.0 m2, on aortic diameter of around 23 mm; and a BSA of 2.5 m2, an aortic diameter of about 25 mm. In women, a BSA of 1.5 m2 should mean an aortic diameter of about 20 mm; a BSA of 2.0 m2, an aortic diameter of 21.6 mm; and a BSA of 2.5 m2, an aortic diameter of 23.5 mm. In the case of an unsuccessful valve repair, a residual annulus that is too small could potentially lead to a patient-prosthesis mismatch during valve replacement.


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  		Table 1. Ideal Effective Orifice Area of the Aortic Annulus in Men and Women on the Basis of Body Surface Areaa

 
According to the work of Swanson and Clark [3] and Brewer and associates [4] on pressurized aortas of human cadavers, we also adjusted the sinotubular junction (STJ) diameter to be slightly larger than the aortic annulus to maintain valve symmetry and the triangular arrangement of the leaflets during systole to reduce fatigue on the leaflet free edge, as shown by Brewer and co-workers. This was achieved by adding intercommissural stitches at the level of the new STJ diameter tied around a Hegar's dilator to fix the STJ diameter 2 to 3 mm larger than the annulus (STJ diameter = 1.16 x annulus diameter according to Brewer and associates). The length of each of the three intercommissural reduction stitches in the perimeter (Pr) should be equal to the length of the reduction in diameter (Dr) of the Dacron graft (Pr = {pi}Dr). The size of the tubular graft is chosen according to the size of the neo-sinus of Valsalva, which should be 30% larger than the aortic annulus (30 to 34 mm), according to Swanson and Clark.

We have applied these principles in our last ten cases with satisfactory results. We believe that these landmarks can inspire surgeons confronted with valve-sparing root reconstruction.

References

  1. Svensson LG. Sizing for modified David's reimplantation procedure. Ann Thorac Surg. 2003;76:1751–1753[Abstract/Free Full Text]
  2. Haycock GB, Schwartz GJ, Wisotsky DH. Geometric method for measuring body surface area: a height-weight formula validated in infants, children, and adults. J Pediatr. 1978;93:62–66[Medline]
  3. Swanson M, Clark RE. Dimensions and geometric relationships of the human aortic valve as a function of pressure. Circ Res. 1974;35:871–882[Abstract/Free Full Text]
  4. Brewer RJ, Deck JD, Capati B, Nolan SP. The dynamic aortic root. Its role in aortic valve function. J Thorac Cardiovasc Surg. 1976;72:413–417[Abstract]

Related Article

Reply
Lars G. Svensson
Ann. Thorac. Surg. 2004 78: 2216. [Extract] [Full Text] [PDF]




This Article
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Miguel Chaput
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