Ann Thorac Surg 2009;87:1917-1918. doi:10.1016/j.athoracsur.2009.02.091
© 2009 The Society of Thoracic Surgeons
New Technology
Invited Commentary
George Magovern, Jr, MD
Department of Surgery, Allegheny General Hospital, 320 East North Ave, 14th Floor, South Tower, Allegheny General Hospital, Pittsburgh, PA 15212
(Email: gmagover{at}wpahs.org).
I read with interest the article by Martens and colleagues [1]. It is important for the present generation of practicing thoracic and cardiovascular surgeons to know that the sutureless 3f Enable aortic bioprosthesis (ATS Medical, Minneapolis, MN) is not the first sutureless aortic valve to be implanted. The first sutureless aortic valve prosthesis was the Magovern-Cromie mechanical fixation aortic valve prosthesis first implanted on January 9, 1963 in Pittsburgh, Pennsylvania. The patient had severe aortic insufficiency. In the late 1950s and through the decade of the 1960s, myocardial protection for aortic valve procedures was limited to either anoxic arrest with cross clamping or direct coronary artery perfusion cannulas placed in the coronary ostia during the valve implantation. Neither of these techniques was ideal. Because most patients referred for surgery had New York heart functional classification IV symptoms and impaired left ventricular function, the operative mortality for aortic valve replacement was high in most centers. This was due to the fact that the operation often required 1 hour or more of cross clamping, resulting in poor myocardial preservation and failure to wean from bypass. The distinguishing feature of the Magovern sutureless aortic valve was that it could be implanted quite rapidly. The prosthesis included a threaded cylinder to which an upper and a lower plate were attached. When the central cylinder was turned by a twist of the insertion tool, the multiple noncutting curved surgical staples protruded from the periphery of the valve base and, when properly seated, were then securely fixed into the surrounding tissue. The design used 32 to 56 staples (varying with the size of the valve), which were moved mechanically at the same time. The staples could easily be fully retracted by turning the insertion tool in the reverse direction. When satisfactory implantation had been achieved, the insertion tool was gently detached and removed, leaving the valve in place. The silicon rubber ball was barium filled for roentgenogram observation, and it was manually placed inside the cage when the insertion tool was removed.
Although the 3f Enable aortic bioprosthesis (ATS Medical) is also faster to implant than the traditional hand-sewn valve replacement devices, the most attractive feature of this bioprosthetic valve is that it should be easier to implant through a minimally invasive incision. Isolated aortic valve implantation through a mid-sternotomy approach is a safe operation with an operative mortality approaching 1% in many large centers. However, the mid-sternotomy approach can be perceived as overly aggressive by patients and referring cardiologists. The more minimally invasive upper sternotomy approach is certainly perceived by patients as more attractive, and thus the challenge for cardiac surgeons in the years ahead will be to develop a new platform to replace the aortic valve through smaller incisions, while maintaining a low operative mortality and morbidity rate. The 3f Enable aortic bioprosthesis should have an important role in minimally invasive approaches, as it should be easier to implant this valve through a small incision, in contrast with hand-sewn prostheses in which placement of annular sutures can be tedious and technically challenging.
Although the percutaneous aortic valve platform has received considerable attention as the next generation aortic valve prosthesis of choice, it is clear that not all patients will be safe candidates for the percutaneous approach due to severe peripheral vascular disease. Thus, the 3f Enable aortic bioprosthesis will likely be an important part of the surgeon's armamentarium in treating patients for aortic valve disease using a minimally invasive platform.
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References
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- Martens S, Ploss A, Sirat S, Miskovic A, Moritz A, Doss M. Sutureless aortic valve replacement with the 3f Enable aortic bioprosthesis Ann Thorac Surg 2009;87:1914-1918.[Abstract/Free Full Text]
Related Article
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Sutureless Aortic Valve Replacement With the 3f Enable Aortic Bioprosthesis
- Sven Martens, Anja Ploss, Sami Sirat, Alexandra Miskovic, Anton Moritz, and Mirko Doss
Ann. Thorac. Surg. 2009 87: 1914-1917.
[Abstract]
[Full Text]
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