| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 2000;70:51-52
© 2000 The Society of Thoracic Surgeons
DR GLENN J. R. WHITMAN (Baltimore, MD): I too am fascinated by the differences seen and the willingness of your group to try out these two different stentless valves. From a personal experience, I have found it difficult to use the Toronto SPV because it has a fixed distance between the coronary ostia and the annulus that you cannot manipulate because you cannot cut into the fabric used to coat the external surface of the valve. In the Freestyle, one can actually shave closer and closer to the pig’s annulus to allow for room in which to sew beneath the patient’s coronary ostia. In your institution’s experience, has that been a factor in operative selection of the Freestyle valve?
DR RILEY: Thank you for your comments. At our institution, all of the Freestyle valves are used as an aortic root replacement. Based primarily on our experience with aortic homografts and others experience with the Freestyle implanted in the subcoronary position, we find it easier and more versatile to use this valve for an aortic root technique.
DR WHITMAN: When you use the Toronto prosthesis, do you find that you are sewing close to the coronary ostia and that this creates a problem for you that leads you to use the Freestyle?
DR RILEY: I think that is a concern, and one of the technical difficulties with that valve is the closeness to the coronary ostia. You have to have very good visualization to avoid occluding either coronary, but that in itself has not been a reason why we have not used that valve.
DR THORALF M. SUNDT III (St. Louis, MO): That is a very nice study, congratulations. One of the curiosities of the stentless age, if you will, is that at a point in time when most have decided that the free-standing root technique is superior to the subcoronary technique when carrying out homograft or autograft valve replacement, we are implanting both types of stentless valves in most instances using a subcoronary technique. Despite the root option, most Freestyle valves end up being placed using a subcoronary technique. As your two groups had valves implanted using different techniques, how much do you think you are comparing two prostheses and how much are you comparing the subcoronary versus a root implant technique? Obviously, the two are interrelated. Not having a group of Freestyles that were done in a subcoronary technique may make that a difficult question to answer.
The second question is, which of these do you think is going to be easier for us to reoperate on in 10 years?
DR RILEY: Thank you. Those are both good questions. The first question as far as whether this is truly a difference between valves or implant technique, I did try to address that. I think that based on our experience we would say that this is probably more a technique-related difference. Others have shown that using the Freestyle valve in a subcoronary position, you have an amount of aortic regurgitation postoperatively similar to the subcoronary Toronto SPV.
With regard to reoperation, we tend to put this in an older patient population, and in this subset as well as our entire series we have not had to reoperate on any of those patients. If it ever arises, I would say that a subcoronary valve is probably going to be an easier reoperation.
DR PAUL KURLANSKY (Miami Beach, FL): I wanted to congratulate you on your study and advancing the field of stentless technology, because I think this approach is going to change our approach to aortic valve disease.
I had a question. As you note in your study, or in your comments, there was a significant difference in the experience of the operators at the time of the study between the Toronto valve and the Freestyle valve. I also noted that the incidence of aortic insufficiency after surgery was a little bit higher than had been noted in the large multicenter study for the approval of the Toronto SPV valve. In view of all this, I was wondering what you might be able to teach us in terms of the use of the Toronto SPV valve, dos and do nots, as it were, or things that you could glean from your experience that might be helpful to other operators.
Also, in regard to one of the previous questions, the problem of distance from the coronary ostia to the annulus can partially be ameliorated by where you take your inlet row of sutures. If you take it lower in the aortic outflow tract—which is safe because it is not a strength layer, it is a positioning layer—you may be able to overcome the distance from the coronary to the annulus. Thank you very much.
DR RILEY: Thank you. With regard to your second question, it is possible to set the SPV lower within the aortic annulus to avoid compromise to the coronary ostia. This concept though is not so easy in practice. As far as guidelines for the Toronto usage, we have modified our usage of this valve a little bit, and in summary.
We now would say that a patient with an asymmetric aortic root or a heavily calcified ascending aorta, as well as a dilated sinotubular junction, would be a contraindication for implantation of this valve. In our experience, any operation that requires tailoring of the aortic root or resizing of the ascending aorta, we would also probably not use this valve. If you are going to use a stentless valve in a younger age population, reoperation may be a more important consideration and the subcoronary implant a better choice. We do not have that data yet.
DR CHRISTOPHER J. KNOTT-CRAIG (Oklahoma City, OK): Could you put your previous slide back up again? I could not resist the temptation to ask you to clarify that last slide on your conclusions. If I understood and read the earlier slides correctly, I believe you show that there was no significant difference in the gradients and there was no significant difference in the incidence of mild aortic regurgitation and there was no difference in the mortality, and yet your conclusion slide says differently. Could you clarify that for me?
DR RILEY: Yes. There was a significant difference in gradient, there was a significant difference in early operative mortality, and there was a significant difference in any aortic insufficiency as well as mild aortic insufficiency.
Related Article
Ann. Thorac. Surg. 2000 70: 48-51.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 |
