ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2008;85:2019-2024. doi:10.1016/j.athoracsur.2007.11.083
© 2008 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Khalil Fattouch
Giuseppe Bianco
Emiliano Navarra
Marco Moscarelli
Giuseppe Speziale
Giovanni Ruvolo
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Fattouch, K.
Right arrow Articles by Ruvolo, G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Fattouch, K.
Right arrow Articles by Ruvolo, G.
Related Collections
Right arrow Valve disease
Right arrowRelated Article

Original Articles: Adult Cardiac

Implantation of Gore-Tex Chordae on Aortic Valve Leaflet to Treat Prolapse Using "The Chordae Technique": Surgical Aspects and Clinical Results

Khalil Fattouch, MD, PhD*, Roberta Sampognaro, MD, Giuseppe Bianco, MD, PhD, Emiliano Navarra, MD, Marco Moscarelli, MD, Giuseppe Speziale, MD, Giovanni Ruvolo, MD

Department of Cardiac Surgery, University of Palermo, Palermo, Italy

Accepted for publication November 9, 2007.

* Address correspondence to Dr Fattouch, Via Liborio Giuffré, 5, University of Palermo, Department of Cardiac Surgery, Palermo, 90127, Italy (Email: khalilfattouch{at}hotmail.com).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Repair of prolapsed aortic valve leaflets has been considered a challenging technique for cardiac surgeons. In this paper we describe our surgical approach, "the chordae technique." It consists of the correction of aortic cusp prolapse by shortening the free margin length and of an adjustment of the leaflets coaptation height by anchoring the prolapsing cusp to the aortic wall at the sinotubular junction level.

Methods: Between February 2003 and December 2006, 26 patients with one or more prolapsed aortic leaflets underwent surgical repair using the new approach. The mean age of patients was 55 ± 10 years. There were 10 (38.5%) patients with grade II aortic valve regurgitation, 4 (15.5%) with grade III, and 12 (46%) with grade IV. Twelve patients had a concomitant aortic root aneurysm requiring surgical treatment. There were 22 patients with tricuspid aortic valve, and 4 were bicuspid.

Results: No in-hospital mortality occurred. The mean in-hospital stay was 8 ± 2 days. The mean clinical follow-up was 14 ± 8 months (range, 4 to 36 months). At follow-up, there were 4 (15.5%) patients with trivial aortic valve regurgitation and 22 (84.5%) patients without aortic valve regurgitation. All patients were free from aortic valve reoperation and free from cardiac and thromboembolism events.

Conclusions: In patients with aortic valve regurgitation and cusp prolapse, functional aortic annulus stabilization and the use of the central chordae allows the correction of cusp prolapse and stabilizes the valve repair at follow-up, avoiding a repeat prolapse. We believe that this approach might represent a valuable and safe technique although long-term follow-up is mandatory.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Aortic valve repair (AVR) has a long history, comparable to mitral valve plasty, but has received considerably less attention than the reconstruction of the atrioventricular valves. This is probably owing to the fact that the surgical results of AVR were less satisfactory than those on the mitral valve, because repair is hampered by the lack of valve tissue available to achieve competence. In the last decade, the surgical results of AVR have dramatically improved, encouraging a new interest and practice in aortic valve reconstruction [1–8].

Although several surgical techniques for AVR have been used with good clinical results, treatment of prolapsed aortic valve leaflets is still a challenge for cardiac surgeons. Nowadays, the surgical approach for leaflet prolapse consists of plication, triangular resection, resuspension, free margin reinforcement, and shortening [9–11].

We describe a new technique for repair of prolapsed aortic valve leaflets that consists of free margin cusp shortening and hanging to the aortic wall, from the noduli of Arantius to the sinotubular junction (STJ), using Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) expanded polytetrafluoroethylene sutures. The aim of this study was to illustrate our surgical approach and to evaluate early and midterm clinical and echocardiographic results.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Patients
Between February 2003 and December 2006, 84 patients with ascending aortic aneurysm or aortic valve insufficiency (AI) underwent aortic valve-sparing operation or AVR in our institute. Among them, 26 patients with one or more prolapsed aortic valve leaflets underwent surgical repair using our approach, "the chordae technique." All patients were informed about the benefits and risks of the new procedures. Each patient signed an informed consent form. The local ethics committee approved this study. Demographics and preoperative clinical characteristics of this cohort of patients are shown in Tables 1 and 2. Twenty-two patients had tricuspid aortic valve, and 4 patients had bicuspid aortic valve. Two patients had endocarditis with cusp perforation.


View this table:
[in this window]
[in a new window]

  		Table 1 Patient Characteristics
 
Echocardiographics Studies
All patients underwent preoperative transthoracic echocardiography as well as intraoperative transesophageal echocardiography (TEE). Echocardiographic studies were performed before surgery to measure the dimensions of the aorta at four different levels (aortic annulus, sinuses of Valsalva, STJ, and ascending aorta at the maximum diameter) to evaluate the severity of AI and the direction of the regurgitant jet, and to detect leaflet prolapse. Long-axis and short-axis views were performed to detect leaflet prolapse. In the long-axis view, the aortic leaflet was defined as prolapsed when parts of the cusp were below the level of the annulus. Cusp prolapse may be partial (prolapse of the free margin of the cusp or the distal part) or complete (whole cusp prolapse or eversion). In the short-axis view, the cusp was defined as prolapsed when the free margin was wrinkled in the closure position and a lack in central leaflet coaptation was found [12]. Data are shown in Table 2.


View this table:
[in this window]
[in a new window]

  		Table 2 Preoperative Aortic Dimensions, Aortic Leaflet Morphology, and Surgical Procedures
 
Surgical Techniques
The surgical procedure was performed through a longitudinal median sternotomy. Intraoperative TEE was used to analyze aortic valve and root anatomy. We focused particular attention on the measurement of diameters of the aortic annulus, the Valsalva sinuses, and the STJ, on the height of leaflets coaptation, on the detection of leaflet prolapse, on cusp calcification, and on fenestration of tissue leaflets. Transesophageal echocardiography was used to judge the adequacy of valve repair intraoperatively. Cardiopulmonary bypass was established between the right atrium and the ascending aorta or femoral artery when the ascending aorta had to be resected. A left ventricular vent was inserted through the superior right pulmonary vein. The aorta was cross-clamped and entirely transected 0.5 to 1 cm above the commissures to preserve the integrity and geometry of the aortic root and to provide a good valve exposure. The heart was protected by antegrade normothermic blood cardioplegia administrated selectively into the coronaries ostia.

Aortic Valve Analysis
First, a careful valve analysis is required. Three 4-0 Prolene sutures (Ethicon, Somerville, NJ) were placed at the level of the three commissures and fixed to the chest wall with three hemostats. The aortic valve leaflet morphology was carefully analyzed. The three interleaflet triangles were explored to detect aortoventricular junction dilatation. A temporary 7-0 Prolene suture that holds together the three cusps was passed in the free margin of the three cusps through the noduli of Arantius, and held up vertically by the assistant surgeon. This maneuver in addition to a gentle radial tension applied on the three commissures helps to maintain leaflet coaptation and allows the evaluation of the free margin leaflet length.

Subcommissural Annuloplasty
The first step of valve repair was the treatment of annular dilatation by subcommissural plasty. This procedure was performed by placing 2-0 Ticron sutures at the base of the interleaflet triangles and reinforcing them by pericardium pledgets. After annuloplasty the annulus was measured, and an equal size Dacron (polyethylene terephthalate fiber) tube graft was selected. A 3- to 5-mm ring was cut from one end of the Dacron graft and used as a ring for the STJ plasty.

Sinotubular Junction Remodeling and Ascending Aortic Management
The second step of valve repair was STJ plasty. If the STJ was found to be dilated and the ascending aorta enlarged (diameter > 4.5 cm), we routinely resected the aneurysm and replaced the ascending aorta with a Dacron prosthesis, choosing an equal graft size or 2 to 4 mm bigger than the size of the aortic annulus (after annuloplasty). The Dacron graft was anastomosed at the STJ level to remodel it. If the STJ was not dilated or was only slightly enlarged, we only remodeled it. The Dacron ring was placed on the inner surface of the aortic wall at the STJ level and fixed to it with three mattress sutures (Prolene 4-0), which were reinforced with Teflon felt strips on the external aortic surface (Fig 1). The purpose of the STJ remodeling procedure, as a fundamental step of AVR, was to ensure leaflet coaptation, to maintain an ideal relationship between the annulus and the STJ, and to avoid future outward displacement of the commissures. This STJ stabilization, using a Dacron ring, was always performed in our technique because it is highly recommendable to use a nonexpansible support for anchorage of the Gore-Tex chordae to avoid future STJ dilatation that could result in cusp tethering with restrictive leaflet motion and aortic valve regurgitation.


Figure 1
View larger version (41K):
[in this window]
[in a new window]

  		Fig 1. Sinotubular junction plasty was always performed as a fundamental step of valve repair. The Dacron ring was placed on the inner surface of the aortic wall at the sinotubular junction level (A) and fixed to it with three mattress semisutures (B) (Prolene 4-0).

 
Leaflet Prolapse Management
The next step was the leaflet prolapse correction. This consists in free margin reinforcement with Gore-Tex (CV-6) suture placed starting from one commissure to the other one as shown in Figure 2A. The second Gore-Tex suture was placed on the free margin of the leaflet from one commissure to the noduli of Arantius and passed through the Dacron ring previously sutured at the STJ level (Fig 2B). A third suture was placed in the same fashion from the opposite commissure of the leaflet to the noduli of Arantius and then through the aorta at the same level of the previous suture (Figs 2C, 3). In this way, 2 free edge sutures were lay out at each commissure and at the level of the STJ in the external side of the aortic wall. The free edge sutures at the level of both commissures can be pulled to shorten the length of the free margin of the cusp. At this stage the aorta was closed and the aortic cross-clamp was removed. Under TEE control, in the beating heart, the amount of the free margin cusp shortening and the height of leaflet coaptation was adjusted by pulling the central artificial chordae and the commissural free arms of the Gore-Tex sutures. In this way, leaflet prolapse can be easily adjusted with the new central chordae and the free arms of the Gore-Tex sutures at the levels of the commissures, leaving them unknotted initially and tieing them subsequently, in the beating heart, guided by echocardiographic control. When satisfactory aortic leaflet coaptation was obtained and nonregurgitant jet was observed by TEE, the free edges of the new chordae were fixed to the aortic wall at the level of the Dacron ring and tied (Fig 3).


Figure 2
View larger version (43K):
[in this window]
[in a new window]

  		Fig 2. The chordae technique: (A) Free edge reinforcement of the prolapsing leaflet is performed with Gore-Tex suture (CV-6) starting from one commissure to another one. (B) A second Gore-Tex suture is applied from one commissure to the noduli of Arantius and successively is hung to the aortic wall at the level of the sinotubular junction. (C) A third Gore-Tex suture is applied in the same manner from the opposite commissure.

 

Figure 3
View larger version (74K):
[in this window]
[in a new window]

  		Fig 3. A section of the aortic root that shows the chordae technique.

 
When the reimplantation technique was performed, we first reimplanted the aortic valve into the Dacron graft and subsequently we corrected the prolapsed leaflet. In this case, STJ remodeling was not performed and the new chordae was anchored to the Dacron graft.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Data of preoperative aortic valve morphology, of aortic root and ascending aorta diameters, and of the surgical procedures are shown in Table 2. Surgical procedures were illustrated for all patients in Table 2. The mean cardiopulmonary bypass and aortic cross-clamp times were 101 ± 21 minutes (range, 70 to 178 minutes) and 88 ± 12 minutes (range, 64 to 154 minutes), respectively. No in-hospital mortality occurred.

One patient had a supraannular aortic wall lesion at the level of subcommissural plasty, between the right coronary cusp and the noncoronary cusp, with right ventricular wall hematoma and right coronary artery compression requiring coronary artery bypass grafting with saphenous vein. Four patients with severe preoperative AI had a trivial aortic valve regurgitation after repair with a central jet that did not require additional re-repair (Table 3). In those patients, cusp prolapse repair was technically achieved by our approach, but the residual AI with central jet was probably caused by abnormal preoperative annular dilatation (see annular sizes in Table 2). The mean postoperative hospital stay was 8 ± 2 days.


View this table:
[in this window]
[in a new window]

  		Table 3 Grading of Aortic Valve Regurgitation Preoperatively and After Surgical Repair
 
Follow-up was complete in all patients. The mean clinical follow-up was 14 ± 8 months (range, 4 to 36 months). All patients were alive at the time of follow-up. The mean New York Heart Association functional class at follow-up was 1.1 ± 0.5. Transthoracic echocardiographic control was performed in all patients. There were 22 patients (85%) without aortic valve regurgitation and 4 patients (15%) with trivial AI (Table 3). The results of valve repair were stable with time. Aortic valve stenosis did not occur. Freedom from reoperation was 100%, and all patients were free from cardiac and thromboembolism events.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
The aortic root composed by the aortoventricular junction, the aortic valve leaflets, the Valsalva sinuses, and the STJ is considered as a single functional unit. Moreover, the STJ is in continuity with the aortoventricular junction at the level of the interleaflet triangles and commissures so that it is regarded as a single structure, namely the functional aortic annulus. Recent advances in the understanding of the different mechanisms of aortic valve regurgitation have resulted in the evolution and application of AVR operations to a larger number of patients with improved long-term results [1–8].

Considering the anatomic and functional structure and dynamics of the aortic root, pathologic changes in any of its components can determine AI. Dilatation of the annulus causes AI with a central jet that, if present for a long time, can lead to leaflet prolapse. Ascending aortic aneurysm with enlargement of the STJ causes outward displacement of the commissures, which avoids central leaflet coaptation, resulting in AI.

The aortic root is in continuity with the anterior leaflet of the mitral valve and is attached to contractile as well as fibrous components of the left ventricle. During systole, the interventricular septum shortens and moves inward, and the anterior leaflet of the mitral valve is pushed down in the direction of the left ventricular apex and away from the left ventricular outflow tract [13, 14]. This leads to a greater tension in the area of the aortic root (noncoronary part) that is attached to the anterior leaflet of the mitral valve. This may explain why the noncoronary aortic annulus has a tendency to dilate more than the other parts of the aortic annulus, leading to noncoronary cusp prolapse. Leaflet prolapse is also commonly related to the free margin elongation.

Surgical treatment of cusp prolapse was first described by Trusler and colleagues [9]. These authors treated the cusp prolapse by plicating the commissural end of the elongated free edge to the aortic wall. In patients with thin cusp tissue, autologous pericardium pledgets can be used to avoid tearing of the tissue.

The triangular resection or plication of the prolapsed leaflet was described by Carpentier [11]. This technique aims to restore the normal length of the free edge. If the leaflet is thickened, a triangle of leaflet tissue is resected with its base corresponding to the free edge and its apex toward the leaflet base. The edges are then joined with interrupted 6-0 Prolene sutures. If the leaflet is thin, a triangular plication is the method of choice. Duran and colleagues [10] described the technique of free margin reinforcement with a double layer of 6-0 Gore-Tex suture passed along the free margin from one commissure to another. This technique is used to correct minor elongation of the free margin, allowing a fine band of fibrous tissue to grow along the suture, reinforcing the free margin of the cusp.

Nowadays, correction of leaflet prolapse has become a routine surgical option in isolated aortic regurgitation, and its use has been introduced also in association with valve-sparing aortic root replacement with satisfactory long-term results [15–17]. However, this type of surgery is still a challenge for surgeons. In case of triangular resection or plication, the difficulty is represented by determination of the width of the base of the triangle at the level of the free margin, and therefore, the amount of tissue resection or free-edge shortening. In cases of free margin reinforcement with Gore-Tex suture, the nature of the suture material and its tendency to slide have resulted in difficulty in establishing the correct length of the free margin that could result in it being too short or too long. These technical difficulties are increased by the fact that surgeons work on an empty nonbeating heart, and in this case the aortic valve is not under blood pressure and the aortic root dynamics cannot be evaluated. Furthermore, the chordae technique finds its rationale in the treatment of cusp prolapse because it corrects the free margin cusp elongation by reinforcement and shortening and allows the surgeon to adjust the correct height of leaflet coaptation and the amount of free margin shortening in the beating heart under TEE control after removal of the aortic cross-clamp. In our series, the chordae technique was effective to treat cusp prolapse in all patients. Among them, 4 patients with severe aortic valve regurgitation and abnormal annular dilatation experienced residual trivial AI postoperatively with a central jet that did not need a second run of cardiopulmonary bypass to repair it again (Table 2). In those patients, intraoperative TEE showed that the leaflet prolapse was corrected effectively but the residual AI was caused by abnormal annular dilatation. In these cases, a suggested surgical strategy could be to restart cardiopulmonary bypass to perform an additional subcommissural plasty below the first one.

Moreover, some authors found that the treatment of aortic leaflet prolapse had failed at long-term follow-up, and the primary mechanism of failure in repair of the prolapsing cusp was mainly the repeated prolapse [3, 8, 18]. We believe that the use of the chordae technique can be helpful in avoiding repeated cusp prolapse and can support the aortic leaflet in cases of patch extension.

We applied this technique in 26 patients who underwent AVR with or without root replacement. In our experience, leaflet coaptation and valve competency were easily achieved. Neither cusp injury nor tethering leading restrictive leaflet motion was observed at mean follow-up (14 ± 8 months). Although immediate and midterm results are satisfactory, in terms of valve competency and opening and closing motion, further experience and long-term follow-up are required to evaluate the durability and efficacy of this technique. We believe that the chordae technique can be introduced in the armamentarium of cardiac surgeons to help them in the new era of AVR.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. El Khoury G, Vanoverschelde JL, Glineur D, et al. Repair of aortic valve prolapse: experience with 44 patients Eur J Cardiothorac Surg 2004;26:628-633.[Abstract/Free Full Text]
  2. Carr JA, Savage EB. Aortic valve repair for aortic insufficiency in adults: a contemporary review and comparison with replacement techniques Eur J Cardiothorac Surg 2004;25:6-15.[Abstract/Free Full Text]
  3. Minakata K, Schaff VH, Zehr JK, et al. Is repair of aortic valve regurgitation a safe alternative to valve replacement J Thorac Cardiovasc Surg 2004;127:645-653.[Abstract/Free Full Text]
  4. Casselman FP, Gillinov AM, Akhrass R, Kasirajan V, Blackstone EH, Cosgrove DM. Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet Eur J Cardiothorac Surg 1999;15:302-308.[Abstract/Free Full Text]
  5. Ahn H, Kim K-H, Kim YJ. Midterm result of leaflet extension technique in aortic regurgitation Eur J Cardiothorac Surg 2002;21:465-469.[Abstract/Free Full Text]
  6. Talwar S, Saikrishna C, Saxena A, Kumar AS. Aortic valve repair for rheumatic aortic valve disease Ann Thorac Surg 2005;79:1921-1925.[Abstract/Free Full Text]
  7. El Khoury G, Vanoverschelde JL, Glineur D, et al. Repair of bicuspid aortic valves in patients with aortic regurgitation Circulation 2006;114(Suppl 1):I-610-I-616.[Medline]
  8. Schafers HJ, Aicher D, Langer F, Lausberg HF. Preservation of the bicuspid aortic valve Ann Thorac Surg 2007;83(Suppl):S740-S745.[Abstract/Free Full Text]
  9. Trusler GA, Moses CAF, Kid BSL. Repair of ventricular septal defect with aortic insufficiency J Thorac Cardiovasc Surg 1973;66:394-403.[Medline]
  10. Duran CG, Kumar N, Gometza B, Al Halees Z. Indications and limitations of aortic valve reconstruction Ann Thorac Surg 1991;52:447-454.[Abstract]
  11. Carpentier A. Cardiac valve surgery: the "French correction." J Thorac Cardiovasc Surg 1983;86:323-327.[Medline]
  12. Le Polain de Waroux JB, Pouleur AC, Goffinet C, et al. Functional anatomy of aortic regurgitation: accuracy, prediction of surgical repairability, and outcome implications of transesophageal echocardiography Circulation 2007;116(Suppl 1):I-264-I-269.[Medline]
  13. Dagum P, Green GR, Nistal FJ, et al. Deformational dynamics of the aortic root: modes and physiologic determinants Circulation 1999;100(19 Suppl):II-54-II-62.[Medline]
  14. Kunzelman KS, Grande J, Davide TE, Cochran RP, Verrier ED. Aortic root and valve relationship J Thorac Cardiovasc Surg 1994;107:162-170.[Abstract/Free Full Text]
  15. Langer F, Graeter T, Nikoloudakis N, Aicher D, Wendler O, Schafers HJ. Valve-preserving aortic replacement: does the additional repair of leaflet prolapse adversely affect the results J Thorac Cardiovasc Surg 2001;122:270-277.[Abstract/Free Full Text]
  16. Schafers HJ, Aicher D, Langer F. Correction of leaflet prolapse in valve-preserving aortic replacement: pushing the limits? Ann Thorac Surg 2002;74(Suppl):S1762-S1764.[Abstract/Free Full Text]
  17. Jeanmart H, De Kerchove L, Glineur D, Goffinet JM, Rougui I, Van Dyck M, et al. Aortic valve repair: The functional approach to leaflet prolapse and valve-sparing surgery Ann Thorac Surg 2007;83(Suppl):S746-S751.[Abstract/Free Full Text]
  18. Langer F, Aicher D, Kissinger A, et al. Aortic valve repair using a differentiated surgical strategy Circulation 2004;110(Suppl):II-67-II-73.[Medline]

Related Article

Invited Commentary
Kenton Zehr
Ann. Thorac. Surg. 2008 85: 2024-2025. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
L. de Kerchove, M. Boodhwani, D. Glineur, A. Poncelet, J. Rubay, C. Watremez, J.-L. Vanoverschelde, P. Noirhomme, and G. El Khoury
Cusp prolapse repair in trileaflet aortic valves: free margin plication and free margin resuspension techniques.
Ann. Thorac. Surg., August 1, 2009; 88(2): 455 - 461.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
G. Panic, M. Ristic, S. Putnik, D. Markovic, I. Divac, and U. U. Babic
A novel technique for treatment of mitral valve prolapse/flail.
J. Thorac. Cardiovasc. Surg., June 1, 2009; 137(6): 1568 - 1570.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
K. Zehr
Invited Commentary
Ann. Thorac. Surg., June 1, 2008; 85(6): 2024 - 2025.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Khalil Fattouch
Giuseppe Bianco
Emiliano Navarra
Marco Moscarelli
Giuseppe Speziale
Giovanni Ruvolo
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Fattouch, K.
Right arrow Articles by Ruvolo, G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Fattouch, K.
Right arrow Articles by Ruvolo, G.
Related Collections
Right arrow Valve disease
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS