Ann Thorac Surg 2007;83:700-702
© 2007 The Society of Thoracic Surgeons
How To Do It
Adjustable Sinotubular Junction for Aortic Valve Reimplantation Procedures
Daniele Maselli, MD*,
Fabio Guarracino, MD,
Pietro Bajona, MD,
Luca Bellieni, MD,
Gaetano Minzioni, MD
Cardiothoracic Department, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
Accepted for publication April 24, 2006.
* Address correspondence to Dr Maselli, U.O. Cardiochirurgia, European Hospital, via Portuense 700, Roma 00149, Italy (Email: dmaselli{at}tiscali.it).
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Abstract
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Sinotubular junction size in aortic valve reimplantation procedures is usually predetermined on the basis of mathematical calculations and intraoperative measurements. We propose a new method for aortic valve reimplantation by which intraoperative measurements can be eliminated and sinotubular junction size adjusted after cross clamp removal to fit the patient’s need. Aortic valve commissures are reimplanted in the expandable skirt of a Valsalva (Vascutek, Renfrewshire, Scotland) graft to realize an oversized sinotubular junction that is subsequently reduced to the proper size by wrapping, with Dacron rings of decreasing size, the neo-sinotubular ridge under transesophageal echocardiographic guidance.
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Introduction
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Aneurysms of the aortic root with aortic regurgitation and preserved aortic valve leaflets can be treated by the reimplantation technique described by David and Feindel [1].
Size of the graft selected for the reimplantation procedure determines the size of the neo-sinotubular junction (STJ), which has a recognized role in aortic valve competence dynamics [2]. Graft size selection is usually based on intraoperative measurements and on mathematical equations developed to adapt graft size to both annulus diameter and average height and free edge length of aortic leaflets [3–7].
We propose a simple modification of current techniques by which fine adjustment of STJ size can be achieved, after completing reimplantation of the aortic valve, and intraoperative measurements of aortic leaflets can be avoided.
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Technique
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The technique is the evolution of the method we recently described to reposition the neo-STJ in aortic valve reimplantation procedures with the Valsalva (Vascutek) graft [8]. Native sinuses of Valsalva are resected leaving the coronaries on buttons and commissural pillars with a sewing margin of 5 mm on pillars and sinus remnants. The aortic annulus is sized by Hegar’s dilators, a 3-mm, bigger Valsalva (Vascutek) graft is selected and its collar is shortened to a minimum. The graft is implanted and its distal portion is cut 3 cm above the skirt and stored. A 20-mm, long ring is cut away from the resected portion of the graft. Annular sutures are passed at the base of the graft and tied on the selected Hegar’s dilator. Commissures are fixed at the ideal height in the expandable skirt of the graft by horizontal mattress sutures. Sutures are passed from inside to outside and are not tied.
After completing subcoronary sutures, the ring is inserted around the body of the graft and lowered to the level of the commissures. The horizontal suture used to position the right-left commissure is passed into the ring’s lower margin and tied. Preventing expansion of the skirt, the ring realizes a new STJ. After completion of the distal anastomosis and aortic cross-clamp removal, competence of the aortic valve is checked by transesophageal echocardiography. If the neo-STJ needs further reduction, the ring is plicated at the middle of the noncoronary sinus. When the desired sinotubular junction is achieved, ring plication is fixed by a polypropylene suture, and horizontal sutures used to fix the right-non and the non-left commissures are passed into the ring at its lower margin and tied. The principle of the adjustable sinotubular junction is illustrated in Figure 1.
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Fig 1. Desired size of sinotubular junction is achieved by "wrapping" the expandable region of a Valsalva (Vascutek, Renfrewshire, Scotland) graft with a ring of Dacron obtained by the distal portion of the graft itself (arrow) (left) and lowered at the level of the neo-sinotubular ridge. The ring can be plicated (middle) to further reduce sinotubular junction size. Finally, (right), the ring is fixed by the horizontal mattress sutures used to re-suspend commissures.
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A 28-year-old man underwent an aortic valve reimplantation procedure for an ascending aortic aneurysm and moderate aortic regurgitation with a central jet using our technique after acquiring informed consent. At operation, a 32-mm Valsalva (Vascutek) graft was implanted. After releasing the aortic cross-clamp, different sizes of the neo-STJ were obtained by lowering in position the 32-mm ring and then reducing its size to 30 and 28 mm. An unwrapped STJ obviously resulted in a central regurgitation due to centrifugal displacement of the aortic commissures. A 32-mm ring resulted in a correct STJ with a correct height and level of aortic leaflets coaptation and no aortic regurgitation or aortic leaflets prolapse (Fig 2, top). A 30-mm ring resulted in a still competent valve, coaptation height, but significantly decreased from 9.9 to 6.5 mm. The level of coaptation moved toward the aortic annulus plane. A 28-mm STJ resulted in prolapse of the aortic leaflets and eccentric aortic regurgitation appeared (Fig 2, bottom). The neo-STJ was fixed at 32 mm.
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Fig 2. (Top) Transesophageal long axis view of the aortic root. The neo-sinotubular junction (arrows) is realized by placing a 32-mm diameter ring around the 32-mm Valsalva graft used to replace the aortic root. The shape of the sinuses is preserved (arrowheads). A nice coaptation height (9.9 mm) of aortic valve leaflets is achieved with no aortic regurgitation and no prolapse. (Bottom) The neo-sinotubular junction diameter is reduced to 28 mm. Aortic leaflets prolapse into left ventricular outflow tract and eccentric aortic regurgitation appears.
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Comment
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Our technique to realize an adjustable STJ in aortic valve reimplantation is based on a simple consideration (ie, because the diameter of the neo-aortic annulus can be determined by the surgeon [6] and commissural height is determined by nature, STJ size is the main determinant of aortic valve competence, given that none of the aortic leaflets are prolapsed). A method to repeatedly adjust STJ on a wide range of values should allow for correct and reversible matching of STJ size to aortic valve leaflets size.
Our method is similar to the Stanford modification of the David V procedure [5] with some difference (ie, the operation is realized with a single graft and STJ size is "custom-made" and not predetermined). Our method can compensate for lack of experience and surgical skill.
Limits: (1) Because the Valsalva (Vascutek) graft height of the STJ is predetermined by design, our technique can obviously be applied only to cases (ie, the vast majority in our experience) in which height of the commissures does not exceed height of the Valsalva (Vascutek) graft skirt; (2) prolapsed aortic valve leaflets are usually treated after achieving the correct STJ size; by using our technique they should be managed before STJ size is fixed, which could result in a suboptimal result. We currently do not recommend use of this technique in the presence of prolapsed aortic valve leaflets.
In conclusion, we propose a technique of aortic valve reimplantation in which STJ size can be repeatedly adapted to match real functional needs and intraoperative measurements and calculations can be avoided.
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References
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- 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;103:617-622.[Abstract]
- Furukawa K, Ohteki H, Cao Z, et al. Does dilatation of the sinotubular junction cause aortic regurgitation? Ann Thorac Surg 1999;68:949-954.[Abstract/Free Full Text]
- David TE, Ivanon J, Armstrong S, Feindel CM, Webb GD. Aortic valve-sparing operations in patients with aneurysm of the aortic root or ascending aorta Ann Thorac Surg 2002;74:S1758-S1761.[Abstract/Free Full Text]
- Svensson LG. Sizing for modified David’s reimplantation procedure Ann Thorac Surg 2003;76:1751-1753.[Abstract/Free Full Text]
- Demers P, Miller DC. Simple modification of "T. David-V" valve sparing aortic root replacement to create graft pseudosinuses Ann Thorac Surg 2004;78:1479-1481.[Abstract/Free Full Text]
- Gleason TG. New graft formulation and modification of the David reimplantation technique J Thorac Cardiovasc Surg 2005;130:601-603.[Free Full Text]
- Labrosse MR, Beller CJ, Robicsek F, Thubrikar MJ. Geometric modeling of functional trileaflet aortic valves: development and clinical applications J Biomech 2005;29xx-xx.
- Maselli D, Minzioni G. A technique to reposition sinotubular junction in aortic valve reimplantation procedures with the De Paulis Valsalva graft Eur J Cardiothorac Surg 2006;29:107-109.[Abstract/Free Full Text]
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D. Maselli, R. De Paulis, R. Scaffa, L. Weltert, A. Bellisario, A. Salica, and A. Ricci
Sinotubular Junction Size Affects Aortic Root Geometry and Aortic Valve Function in the Aortic Valve Reimplantation Procedure: An In Vitro Study Using the Valsalva Graft
Ann. Thorac. Surg.,
October 1, 2007;
84(4):
1214 - 1218.
[Abstract]
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Abstract
Introduction
