Ann Thorac Surg 1997;63:1157-1158
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Ronald C. Elkins, MD
Department of Thoracic Surgery, University of Oklahoma Health Science Center, PO Box 26901, 920 Stanton L. Young Blvd, Suite 4SP250, Oklahoma City, OK 73104
See also page 1155.
Eishi and associates report the successful management of a patient with significant dilatation of the aortic annulus and of the ascending aorta with an annuloplasty technique consisting of plication of the three commissures of the aortic annulus, support of the plicated annulus with an autologous pericardial strip, and a longitudinal aortoplasty by plication of the distal native ascending aorta. The early results with this management technique were quite successful. Doctor Tirone David has recently reported on the intraoperative measurements of the aortic and pulmonary root in 77 patients. Reduction in the diameters of the aortic annulus and sinotubular junction was performed in 27 patients, reduction of the aortic annulus in an additional 12, and of the sinotubular junction alone in 10. The operative technique described by Dr David consists of plication of the aortic annulus involving the two commissures associated with the noncoronary leaflet. It is Dr David's opinion that the dilatation that occurs in patients with aortic insufficiency and a bicuspid valve occurs primarily in the noncoronary sinus and that the aortic annuloplasty should be limited to this area of the aortic annulus. It is also his contention that the appropriate sizing for the aortic annulus should be based on the measured diameter of the sinotubular junction of the pulmonary valve with the assumption that the pulmonary annulus is normally 10% larger than the diameter of the sinotubular junction. Using this technique he reports excellent midterm results with this operative procedure.
At our institution we have noted that failure of the Ross operation due to progressive autograft valve insufficiency has been associated with dilatation of the aortic annulus that may be rapidly progressive and associated with early as well as late failure. Management of this complication and prevention of aortic annular dilation was accomplished with the use of an aortic annuloplasty technique that is a modification of a technique described by Alain Carpentier. Fixation of the aortic annulus after annuloplasty has been accomplished with the use of an external woven Dacron strip to ensure stabilization of the reduction annuloplasty. This technique has become a very important modification of the Ross operation for management of patients who have aortic annular dilatation. These patients, most of whom have evidence of dilatation of their ascending aorta and in some the presence of an ascending aortic aneurysm, have required longitudinal aortic annuloplasty for those with dilatation and replacement of the ascending aorta with a Dacron graft in those patients with an aneurysm. Early and midterm results have demonstrated the efficacy of this approach. I compliment Eishi and associates on an excellent case report and an excellent result in this patient who is a good candidate for a Ross operation if one uses a technique that reduces the aortic annulus circumference to a size that is appropriate for the pulmonary autograft valve. We have reduced the aortic annulus circumference or size to the normalized size based on the patient's body surface area. Doctor David has used a size based on measurement of the patient's pulmonary valve sinotubular dimension; both of these appear to be effective in the early and midterm results.
Related Article
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Pulmonary Autograft Implantation in the Dilated Aortic Annulus
- Kiyoyuki Eishi, Shunsuke Nakajima, Kiyoharu Nakano, Yoshio Kosakai, Norifumi Nakanishi, Toshikatsu Yagihara, and Shinichi Takamoto
Ann. Thorac. Surg. 1997 63: 1155-1157.
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