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Six stitches to create a neosinus in David-type aortic root resuspension

2007; Elsevier BV; Volume: 133; Issue: 2 Linguagem: Inglês

10.1016/j.jtcvs.2006.09.036

1097-685X

Anton Moritz, Petar Risteski, Sait Mesut Doğan, Hakan Macit, Birkan Akbulut, Andreas Zierer, Tayfun Aybek,

Cardiac Valve Diseases and Treatments

In the past decade, aortic valve–sparing procedures for aortic root dilatation have gained popularity among surgeons.1David T.E. Feindel C.M. An aortic valve–sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.J Thorac Cardiovasc Surg. 1992; 103: 617-621PubMed Google Scholar The David technique, originally described as reimplantation of the aortic valve in a cylindric tube graft (David I), has been shown to be associated with certain drawbacks, particularly increased leaflet stress during opening and closing2Leyh R.G. Schmidtke C. Sievers H.H. Yacoub M.H. Opening and closing characteristics of the aortic valve after different types of valve-preserving surgery.Circulation. 1999; 100: 2153-2160Crossref PubMed Scopus (253) Google Scholar and possible abrasion of the leaflets as they touch the prosthetic wall. Furthermore, the lack of sinuses may affect the coronary flow.3De Paulis R. De Matteis G.M. Nardi P. Scaffa R. Bassano C. Chiariello L. Analysis of valve motion after the reimplantation type of valve-sparing procedure (David 1) with a new aortic root conduit.Ann Thorac Surg. 2002; 74: 53-57Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Since 1992, this technique has undergone several modifications and refinements4Demers P. Miller D.C. Simple modification of “T David-V” valve-sparing aortic root replacement to create graft pseudosinuses.Ann Thorac Surg. 2004; 78: 1476-1481Abstract Full Text Full Text PDF Scopus (108) Google Scholar to avoid these imperfections. Various attempts to restore the sinuses of Valsalva during the valve-sparing procedure have been reported.2Leyh R.G. Schmidtke C. Sievers H.H. Yacoub M.H. Opening and closing characteristics of the aortic valve after different types of valve-preserving surgery.Circulation. 1999; 100: 2153-2160Crossref PubMed Scopus (253) Google Scholar, 4Demers P. Miller D.C. Simple modification of “T David-V” valve-sparing aortic root replacement to create graft pseudosinuses.Ann Thorac Surg. 2004; 78: 1476-1481Abstract Full Text Full Text PDF Scopus (108) Google Scholar, 5Cochran R.P. Kunzelman K.S. Eddy A.C. Hofer B.O. Verrier E.D. Modified conduit preparation creates a pseudosinus in an aortic valve-sparing procedure for aneurysm of the descending aorta.J Thorac Cardiovasc Surg. 1995; 109: 1049-1058Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar A specially designed prosthesis with a bulge at the base is now available (Sulzer Vascutek, Renfrewshire, United Kingdom). These modifications, however, do not create tear-shaped, natural sinuses for a trilobed aortic root but rather result in an ectatic and evenly spherical bulge that accommodates the natural valve. We present a simple and reliable modification to create trilobed neosinuses in a Dacron polyester fabric tube graft to more closely resemble the natural aortic root. The base of the aortic root is dissected circumferentially for adequate exposure. The sinuses of Valsalva are excised, leaving approximately 4 to 5 mm of aortic wall adjacent to the insertion line of the leaflets. In acute dissections, the wall layers of the aortic root are reconstructed at this point with gelatin-resorcin-formol surgical glue (Colle Chirurgicale; Cardial SA, St Etienne, France) or sutures. In patients with a normal and nondilated annulus, the graft is matched to the annular diameter, adding about 2 mm for aortic wall thickness. For creation of the neosinuses, an additional 5 to 7 mm is added. The graft is slightly beveled to account for the ventricular muscle extension into the commissure between the right and left coronary sinuses. Three neosinuses are shaped by plicating the base of the graft with three 4-0 braided polyester sutures. At the base of each commissure, 5- to 7-mm bites (depending on the amount of planned diameter reduction) are passed parallel to the lower edge of the prosthesis. The second bite of the same suture is passed perpendicularly to the first to catch 5 to 7 mm of prosthesis height (Figure 1, 1 and 2). Placing three stitches at the base in such fashion reduces the diameter and local height of the base and provides a more physiologically rounded triangular shape. Transmural mattress sutures are placed just below the leaflet insertion to the aortic wall. These sutures are then passed through the graft and tied. The valve is resuspended with pledgeted polypropylene sutures above the commissures. Bites are taken 5 to 7 mm wider at the prostheses. This creates the anatomic diameter reduction of the sinotubular junction. Again, three 4-0 stitches are placed at the outside to reinforce the diameter reduction, and the perpendicular bites again reduce the height at the commissures to increase the bulge of the sinuses (Figure 1, 3 and 4). Finally, the aortic wall remnant is sutured to the graft with a continuous mattress suture and the coronaries are reimplanted. The sinuses of Valsalva and their flow dynamics have an important influence on cusp dynamics and coronary flow. The natural radicular expansion of the aortic root cannot be approximated by this type of repair. Modifications of the David operation4Demers P. Miller D.C. Simple modification of “T David-V” valve-sparing aortic root replacement to create graft pseudosinuses.Ann Thorac Surg. 2004; 78: 1476-1481Abstract Full Text Full Text PDF Scopus (108) Google Scholar create pseudosinuses with plication sutures at both the base and the sinotubular junction of the graft. Placing only three sets of plication sutures, however, reducing height and diameter, allows generation of a root better resembling the natural trilobed geometry. The nearly normal anatomy was demonstrated in control computed tomographic scans (Figure 2). In addition, there is no need for a second, smaller tube graft above the sinotubular junction4Demers P. Miller D.C. Simple modification of “T David-V” valve-sparing aortic root replacement to create graft pseudosinuses.Ann Thorac Surg. 2004; 78: 1476-1481Abstract Full Text Full Text PDF Scopus (108) Google Scholar or of a prosthesis-to-prosthesis suture line. This technique is safe and simple to perform, and we believe it is more reproducible as an attempt to recreate the physiologic geometry of the root. It is easy to individually tailor in case of uneven distribution of the commissures, different heights of the commissures, or other variations seen as a result of root dilatation or aortic incompetence. The only graft that incorporates sinuses of Valsalva, the Valsalva graft (Sulzer Vascutek), as introduced by De Paulis and associates,3De Paulis R. De Matteis G.M. Nardi P. Scaffa R. Bassano C. Chiariello L. Analysis of valve motion after the reimplantation type of valve-sparing procedure (David 1) with a new aortic root conduit.Ann Thorac Surg. 2002; 74: 53-57Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar is limited by the predetermined height of the sinus portion and fixed diameters of the large and small parts of the graft, making it unsuitable for some patients with very high commissures, particularly some with Marfan syndrome. The base of the graft is even and thus does not follow the muscular shelf of the septum. It is therefore sometimes difficult to position the lower ring of the graft below the aortic valve insertion. We have performed our first modification since 2000, creating pseudosinuses in 47 patients with good perioperative clinical and echocardiographic results. In addition, measurements of root dynamics with echocardiographic M-mode technique showed significant stress reduction on the aortic leaflets and absence of leaflet strike on the graft wall. The final change presented here restores nearly normal aortic root geometry and can be easily modified to accommodate various anatomic situations.