2. ⢠Conventional treatment of patients with aortic
root pathologyâusing a composite tube graft
⢠lifelong anticoagulation,
⢠risk of thromboembolismand bleeding,
⢠effects of cerebral microemboli,
⢠thecontinuous burden to the left ventricle owing to
increasingaortic outflow resistance.
⢠the psychologic drawback of heart valve noise,
Interactive CardioVascular and Thoracic
Surgery 13 (2011) 189-197
J Thorac Cardiovasc Surg 2008;116:990-996
3. ⢠Option for children and young adults with aortic
sinus +/- ascending aneurysm
ďżźďżź
⢠preserve N restore valve competence
⢠Avoids problems of valve prostheses
Valve Sparing Root Replacement
Valve Sparing Aortic Root Replacement: Technical Tips and Pitfallsďżź
Duke E. Cameron, MD
Division of Cardiac Surgery The Johns Hopkins Hospital Baltimore, Maryland
Adult Cardiac Skills Course AATS 2012
5. Dacron graft is anchored to the
aortoventricular junction. The native aortic
valve is then resuspended within the vascular
graft.
Dacron graft is tailored to conform
the shape of the 3 aortic sinuses
and then anastomosed to the aortic
root.
6. Valve sparing aortic replacement â root
remodeling
Operative Techniques in Thoracic and Cardiovascular Surgery
2005;10(4):246â258
7. The diseased aortic sinuses are excised down
to the aortic annulus, which is always healthy
and can hold sutures securely even in patients
with acute dissection.
choosing an appropriately sized Dacron tube,
passing horizontal mattress sutures just above
the top of each commissure and stretching the
three commissures in a vertical direction while
observing the position of the cusps.
8. choosing graft size and take a graft of
approximately 1 to 2 mm smaller than the
diameter of the aorto-ventricular junction.
Three longitudinal cuts are
made in one of the ends of the
graft. The length of these
longitudinal cuts should be
approximately three fourths
of the diameter of the graft.
The ends are rounded (B)
9. suture are passed from the
inside to the outside of the
graft immediately ahovr the
end of the longitudinal cuts,
and then from the inside to
the outside of the rtminants
of the aortic.
The Dacron graft is then
sutured to the remnants of
the aortic sinuses along the
aortic annulus. It is safer to
start at the commissural level
and to sew toward the central
portion of the sinus to
prevent maldistrihution of the
tailored graft along the aortic.
annulus.
The graft should lie inside the
remnants of the aortic
sinuses.
10. aortic valve is tested for incompetence
If the. leaflets do not touch each other in the center, the graft may be too
large; this can he corrected by sewing the diameter of the sinotubular
junction.
If the leaflets coapt excessively, thev may prolapse under pressure.
the best method is by Doppler echocardiography after discontinuation of
cardiopulmonary bypass.
11. The right and left coronary arteries are then
reimplanted into their respective sinuses by
making an opening in the graft and suturing
the remnants of the sinus wall around each
cornnary artery.
12.
13. Valve-sparing aortic root replacement: the
inclusion (David) technique
Operative Techniques in Thoracic and Cardiovascular Surgery 2005;10(4):246â258
David TE, Feindel CM: An aortic valve-sparing operati(in for patients with aortic incompetence
and aneurysm of the asrending aorta. J Thorac Cardiovasc Surg 103:617-622, 1992
14. For the correct sizing of the appropriate Dacron graft, commissures must be pulled up to
create a virtual cylinder with cusp coaptation of 30â50%.
15. Horizontal mattress sutures without pledges
are placed in one lane underneath the sinuses
for later fixation of the graft to the aortic root.
When knots of the horizontal
mattress are gently tied, the
graft must be pushed down and
held in position by the assistant.
A pivotal step of the
reimplantation procedure
is the posi- tioning of the
commissures high enough
into the Dacron tube by
pulling on the stay
sutures, reshaping a
correct geometry of the
valve.
16. Valve implantation:
slightly pulling on both the commissure and the
vascular graft before stitching the sutures through
the graft.
the graft should extend roughly by half of its
maximum length at this segment.
Insertion of saline allows a first judgment of
leakproofness of the valve.
After completion of the reimplantation,
the valve must appear in means of the
geometry like a âMercedes starâ, but indi-
vidual differences in length of cusps are
possible.
17. Completion of the procedure: Coronary ostia
are reim- planted into the Dacron prosthesis
by use of 5-0 monofilament run ning suture
The reimplantation of partially resected
sinuses of valsalvae starts at the Nadir of the
three coronary sinuses, each with double
armed monofila- ment sutures going up to
both commissures, where sutures were tied to
each other. This suture line must be
hemostatic! Stay sutures are tied and cut too.
18. Relationship between height of resuspension
of the reimplanted valve and occurrence of
postoperative aortic insufficiency.
20. ď- Optimal STJ diameter (+3-4mm)
ď- Free leaflet length (+3-4mm)=graft diameter
ď- Height of L-NC commissure
- BSA
-aortic annulus should not exceed
- the length of the free margin of the leaflets
- twice the height of the leaflets
⢠If in doubt, go with larger graft
⢠If in severe doubt, use a 30mm graft
â˘Never apologize for a Bentall
ďżź
Selection of Graft Size
Valve Sparing Aortic Root Replacement: Technical Tips and Pitfallsďżź
Duke E. Cameron, MD
Division of Cardiac Surgery The Johns Hopkins Hospital Baltimore,
21. Valve Sparing Aortic Root Replacement: Technical Tips and Pitfallsďżź
Duke E. Cameron, MD
Division of Cardiac Surgery The Johns Hopkins Hospital Baltimore,
Maryland
Adult Cardiac Skills Course AATS 2012
23. Diagram of aortic valve lesions and
corresponding re- pair teechniques.
Aortic. regurgitation with
decreased cusp moobilitydity.
Iliagram of aortic. valve lesions and
correcspondingrt.pair techniques. Aortic
reguritation with increased cusp mobility
Diagram of aortic. valve lesions and
rorrrsponding repair technic1ue.s. Aortic re-
gurgitation with normal cusp mobility.
25. In 2003, Miller introduced a classification to the Tirone David's
⢠David-I is the original reimplantation procedure using a cylindrical tube
graft,
â˘David-II is the original Yacoub remodeling procedure,
â˘David-III is the remodeling procedure with an external narrowing
annuloplasty strip,
â˘David-IV is reimplantation using a 4-mm larger graft size with plication of
the graft circumferentially at the sinotubular junction (STJ) above the tops of
the commissures, and
â˘David-V is reimplantation using an even larger graft size, which is ânecked
downâ at both the bottom and the top ends to create graft pseudosinuses
Miller DC
. Valve-sparing aortic root replacement in patients with the Marfan syndrome. J Thorac Cardiovasc Surg
2003;125:773-778
26. ⢠whether the reimplantation (David) technique or the
remodeling (Yacoub) technique provides the optimum
event free survival
⢠14 papers provided the best evidence
⢠total of 1338 patients (Yacoub technique in 606 and
David technique in 732)
⢠13 centres were includedInteractive CardioVascular and Thoracic
Surgery 13 (2011) 189-197
J Thorac Cardiovasc Surg 2008;116:990-996
27. ⢠Early mortality ranged from
â 0% to 6.9% for the Yacoub technique and
â 0â6% for the David technique.
⢠In the largest available series reported by David et al.
in 2010
â 1.6% in the Yacoub group and
â 1.7% in the David group.
⢠acute type A dissection ,the overall early mortality
was 17%
AATS meting 2012. ctsnet.org2012
Interactive CardioVascular and Thoracic
Surgery 13 (2011)
jtcs.ctsnetjournals.org tcvs.2008
J Thorac Cardiovasc Surg 2008;116:990-996
Circulation. 2002;106[suppl I]:I-229-I-233
28. Clinical bottom line
⢠The results for both techniques were almost comparable.
⢠Bicuspid
⢠favour of the David technique rather than the Yacoub
technique in pathologies such as
⢠Marfan syndrome,
⢠acute type A aortic dissection
⢠excessive annular dilatation
AATS meting 2012. ctsnet.org2012
Interactive CardioVascular and Thoracic
Surgery 13 (2011)
jtcs.ctsnetjournals.org tcvs.2008
J Thorac Cardiovasc Surg 2008;116:990-996
Circulation. 2002;106[suppl I]:I-229-I-233
29. ⢠less freedom from AR in the Yacoub than the David
⢠not been associated with thromboemboliccomplications, the
riskof valve endocarditis
⢠Predictor of (early) failure
â Patient selection
â Cusp repair
â Coronary reimplantation AATS meting 2012. ctsnet.org2012
Interactive CardioVascular and Thoracic Surgery 13 (2011)
jtcs.ctsnetjournals.org tcvs.2008
J Thorac Cardiovasc Surg 2008;116:990-996
Circulation. 2002;106[suppl I]:I-229-I-233
.
30. Left to right: remodeling, modified
remodeling, sinus prosthesis, modified sinus
prosthesis, reimplantation, and modified
reimplantation.
In vitro hydrodynamics, cusp-bending deformation, and root distensibility for
different types of aortic valveâsparing operations: Remodeling, sinus prosthesis,
and reimplantation
Armin Erasmi, MD, Hans-H. Sievers, MD * , Michael Scharfschwerdt, Thorsten
Eckel, Martin Misfeld, MD, PhD
Department of Cardiac Surgery, University Clinic of Schleswig-Holstein, Campus
Luebeck, Luebeck, Germany.
33. ⢠Reimplantation of the aortic valve in a rigid tube leads toa nonphysiologic movement of the valve leaflets similar
to thatobserved for stented bioprotheses, exposing the leaflets toincreased bending stresses and thus to the risk
of prematurefailure. They maintain that this operation is adequateto avoid secondary dilatation of the aortic root
and still topreserve or restore aortic valve function.
⢠Remodeling of the aortic root preserves some distensibility,with the propensity to reduce aortic outflow
resistance andthus to lessen the load on the ventricle. It further allowsfor creation of a pseudosinus, allowing
nearly normal openingand closing characteristics of the aortic valve and enhancingits durability [11, 12].David
and Feindel8
have pointed out that, in extensive root dilatation, not onlythe sinuses of Valsalva are dilated but
also the fibrous portionsof the root inferior to the valve insertion line (ie, fibroustrigone and membranous
septum). To correct the root also atthis level, they have proposed mobilization of the root, anchoringa Dacron
graft to the aortoventricular junction, and reimplantationof the aortic valve within the vascular graft.
⢠Nevertheless, debate still exists about which technique to applyto different pathologic conditions and, more
generally, whatthere is to gain from using valve-sparing techniques comparedwith the standard composite
prostheses. We therefore reviewedour 10-year experience with both types of valve-preserving techniques.
34. ⢠Operative Technique
After median sternotomy, standard cardiopulmonary bypass wasinitiated with a membrane oxygenator (Hollow Fiber Oxygenator,Spiral Gold,
Baxter, Puerto Rico) using antegrade crystalloidor blood cardioplegia. Profound hypothermia (15° to 18°C)was used when circulatory arrest was
necessary. The side ofarterial cannulation was the femoral artery in 32 patients,the right subclavian artery in 5, a combination in 6, and the
ascending aorta in a nondissected area in 121. Venous cannulationwas performed through the right femoral vein in 9 patients andthrough the right
atrium in the rest.
⢠The operative technique of the remodeling technique (group A)and the reimplantation technique (group B) has been describedin detail [4, 5].
Briefly, the ascending aorta was transected3 mm above the commissures. The sinuses of Valsalva were excised,leaving a 2-mm rim attached to the
crown-shaped annulus. Ifthe dissection affected the aortic root, gelatin-resorcin-formaldehydeglue (GRF; Cardial, Saint E'tienne, France) was used
to readaptthe dissected layers of the aortic wall before the sinuses wereexcised. The size of the tube used was determined by the distancebetween
the straightened commissures giving a macroscopic pictureof appropriate cusps coaptation and the diameter of the baseof the aortic annulus,
measured by means of a Hegar dilator[16].
⢠According to the adopted procedure, a trimmed or straight HemashildGold tube (Meadox Medicals, Oakland, NY), made with Dacron (DuPont,
Wilmington, DE), was used to replace the excised sinuses. Insome patients, one or more of the sinuses were macroscopicallyintact without any
changes of the underlying pathology; onlyone sinus was replaced in 13 of these patients, and in 5 patientsonly two of the three sinuses were
replaced using the surgicalprinciples of the remodeling technique. In some patients ofthe remodeling group, we used our own technique of
individualreplacement of each sinus with a single piece of Dacron tubeand additional replacement of the ascending aorta.
⢠In most of the patients, the distal anastomosis was performedin an open fashion using circulatory arrest
35. reimplantation technique caused significantly
higher pressure gradients
Bending deformation indices for all valve-
sparing techniques were more than twice
those of the native aortic root and increased in
relation to the degree the root was fixed with
synthetic noncompliant material.
Aortic root distensibility, expressed as
diastolic-to-systolic change of area, decrea
in all surgical procedures compared with th
of the native aortic root
36. Schematic drawing of measured aortic valve opening and closing characteristics of 3
distinct phases: a-b, rapid valve opening; b-c, slow systolic closure; and c-d, rapid valve
closing movement. RVOT indicates rapid valve opening time; D1, maximal leaflet
displacement; RVCT, rapid valve closing time; ET, ejection time; SCD, slow closing
displacement; and D2, leaflet displacement before rapid valve closing.
37. Diagram of cyclic changes in dimensions
derived from mean values of measured data at
base, sinus, and commissural levels. Note
reduced distensibility in group A at all levels of
aortic root
Opening and Closing Characteristics of the Aortic Valve After Different Types of Valve-Preserving Surgery
Rainer G. Leyh, MD; Claudia Schmidtke, MD; Hans-Hinrich Sievers, PhD, FETCS; Magdi H. Yacoub, PhD, FRCS
From the Departments of Cardiac Surgery, Medical University of LĂźbeck, LĂźbeck, Germany (R.G.L., C.S., H.-
H.S.), and the National Heart and Lung Institute at the Imperial College of Science, Technology, and Medicine,
London, UK (M.H.Y.).
38. EVOA is constant in both compliant and stiff
roots
Aortic valve regional
stresses in the normal aortic
root and clinical valve-
sparing models. *P = .0001
and {dagger}P = .0005
indicate significant
difference as compared with
the normal root model. b,
Schematics of altered leaflet
stress patterns in the graft
models as compared with
normal.
RE-CREATION OF SINUSES IS IMPORTANT FOR SPARING THE
AORTIC VALVE: A FINITE ELEMENT STUDY
K. Jane Grande-Allen, PhDa, Richard P. Cochran, MDb, Per G.
Reinhall, PhDc, Karyn S. Kunzelman, PhDb
From the Department of Biomedical Engineering, Cleveland Clinic
Foundation, Cleveland, Ohioa; Division of Cardiothoracic Surgery,
University of Wisconsin, Madison, Wisb; and Department of
Mechanical Engineering, University of Washington, Seattle, Wash.c
39. Both techniques are widely used in the case of aortic root aneurysms associated
with non-diseased aortic valves.
The classic remodeling technique allows a good anatomical reconstruction of
the sinuses of Valsalva but has a higher incidence of residual valve
regurgitation.
the classic reimplantation technique permits more stable results through
annulus stabilization but completely abolishes the sinuses of Valsalva
40. Adapting the Valsalva graft to the patient's
anatomy (I). When the height of the
commissures matches the height of the âskirtâ
the collar is cut out and the lower row of
sutures are passed at the base of the skirt. In
this way the top of the commissures will reach
the level of the new sino-tubular junction (the
connection between the two sections of
Dacron)
Adapting the Valsalva graft to the patient's
anatomy (II). When the height of the
commissures is shorter than the height of the
âskirtâ the collar is cut out and the lower row of
sutures are passed at the corresponding level
inside the skirt. The top of the commissures
will therefore be at the level of the new sino-
tubular junction.
41. Adapting the Valsalva graft to the patient's anatomy (III). In the
rare cases when the height of the commissures is longer than the
height of the âskirtâ the collar can be utilized to secure the lower
row of sutures, to increase the length of the reconstructed root
and to consent that the top of the commissures reaches the level
of the new sino-tubular junction.
42. Because of its particular shape, the use of the Valsalva graft simplifies
the surgical procedure by offering:
â˘Decreased tension during coronary artery suturing
â˘Decreased tension after graft pressurization
â˘Increased anatomical adaptability
â˘Decreased potential for suture bleeding and pseudoaneurysm
formation
â˘Easier access to the coronary anastomosis at the end of procedure
43.
44.
45. Remodeling of the aortic root combined to an
expansible aortic ring annuloplasty
46. Standardized and physiological approach to
aortic valve repair according to each
phenotype of ascending aorta. (Reproduced
from Ref. [17] with permission from Elsevier.)
47. Remodeling of the aortic root
associated to an external
subvalvular aortic annuloplasty
(CAVIAAR technique),
combining advantages of the
original remodeling and
reimplantation techniques:
âremodelingâ technique
provides the most
physiological reconstruction of
the root, but it does not
address the dilated annular
base. Alternatively, the
reimplantation, as an inclusion
technique, provides a
subvalvular annuloplasty to
the detriment of valve
dynamics [6, 7,
9,10,11,12,13,14,15,16].
(Reproduced from Ref. [17]
with permission from Elsevier.)
48. Criteria for the choice of the subvalvular aortic
ring and Valsalva graft.
49. First step of valve repair: alignment of
adjacent cusp free edges
Placement of the subvalvular expansible aortic
ring (A) and final aspect of the aortic root (B).
(Reproduced from Ref. [17] with permission
from Elsevier.)
Placement of the five anchoring
subvalvular âUâ stitches
50. Aortic root aneurysm for bicuspid valves: remodeling of the
aortic root, resuspension of cusp effective height and
subvalvular aortic annuloplasty.
51. ⢠One hundred and eighty-seven patients underwent remodeling associated with a subvalvular
aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated:
Group 1: gross visual estimation (74 patients), Group 2: alignment of cusp free edges (62 patients),
Group 3: two-steps approach associating alignment of cusp free edges with effective height
resuspension (51 patients). A composite outcome was defined as recurrence of aortic insufficiency
grade 2 and/or reoperation. Operative mortality was 3.2% (20). Treatment of cusp lesion wasâ§
most frequently performed in Group 3 (70.6%, vs. 20.3% Group 1 and 30.6% Group 2, P 0.001).âŞ
Nine patients required reoperation during follow-up [24 months (12â45)], from Group 1 (6) and
Group 2 (3). At one year, no patients in Group 3 presented with composite outcome events (vs.
28.1% Group 1, 15% Group 2, P 0.001). Residual aortic insufficiency and tricuspid anatomy wereâŞ
independent risk factors for composite outcome in Groups 1 and 2. Annulus diameter, Marfan
syndrome and cusp repair had no effect on aortic insufficiency recurrence or reoperation [
52. Conclusions: In vitro the various aortic valveâ
sparing operations differed charac- teristically
in their ability to spare valve function, none of
them completely meeting native valve
behavior. The remodeling techniques
exhibited valve dynamics closest to those of
the native aortic root. The more the aortic
valve is fixed with noncom- pliant prosthetic
material, the more the native root dynamics
are impaired.
Editor's Notes
Even, post valve sparing procdr, there r unphysiologic movement of valve cusp, still gradien occurred were equal to normal cusp motion.. <<5mmHg
Both techniques are reported to provide excellent functional results, with a low pressure gradient and no or minimal aortic regurgitation
remodeling technique described by Yacoub and colleagues which replaces the sinuses separately, and
reimplantation technique of David and Feindel which replaces the entire wall of the aortic root with a straight prosthetic tube
The opening in the graft should he at least twice as large as the diameter of the coronary artery hcause a thick pseudointima (up to 3 mm) develops along the anastomotic line
Excessively large orifices in the graft may cause late aneurysm of the remnants of the aortic sinus tissue and
too small orifices may result in late stenoses of the c:oronary artery ostia. The upper part of the Dac-ron graft is then sutiired to the distal aswntling aorta or to a graft that may have been used to replace the transverse aortic. arch.
The ascending aorta is transected 1 cm above the commissures of the aortic valve (A). The aortic leaflets are then carefully inspected. One needs not to measure the length of the free margin and the length of the base of each leaflet to determine if it they are overstretched or not. This assessment can be performed simply by holding the arterial walls immediately above the commissures of a leaflet at an appropriate distance from each other and observing the leaflet. If it does not prolapse, it is an indication that its free margin is shorter than its base. If all three leaflets are fairly normal or only minimally stretched, remodeling of the aortic root with preservation of the aortic valve is feasible.The aortic root is circumferentially dissected down to the level of the aortoventricular junction. The aortic root has to be freed from the pulmonary artery, the right ventricle, and the roof of the left atrium. Next, all three aortic sinuses are excised, leaving only 4 to 6 mm of arterial wall attached to the aortic annulus and around each coronary artery orifice. Both coronary arteries should be mobilized for a length of 1.5 to 2 cm to facilitate reimplantation later on (B)
5. The length of the free margin and the height of each leaflet are measured and averaged. The diameter of the aortic annulus should not exceed the length of the free margin of the leaflets or twice the height of the leaflets. Because these patients have annuloaortic ectasia, a reduction in the diameter of the aortic annulus is often necessary. It is important to remember that the dilatation of the aortic annulus occurs only along its fibrous components. Thus, reduction of the aortic annulus is performed along its fibrous portion. This is accomplished by an aortic annuloplasty. Multiple horizontal mattress sutures of 4-0 or 3-0 multifilament polyester are passed from the inside to the outside of the fibrous portion of the left ventricular outflow tract immediately below the lowest level of the aortic annulus through a single horizontal plane (A, B). These sutures are then passed through a strip of Dacron fabric to reduce the diameter of the aortic annulus, especially underneath the commissures of the noncoronary leaflet (C). All sutures are tied outside of the aortic root (D). The aortic annuloplasty is completed.
Bsa <2 m2.. 21 sizerâŚ.. 23 sizer
Pitfall.. Obstruc anastm of buttoned coronary.. Lead to LV failure
Initially only patients with normal aortic valve leaflets had these operations, but more recently we utilized them in patients with prolapse of a single leaflet and in those with a bicuspid aortic valve
The AV leaflets are often normal for age, and reduction of the sinotubular junction with an appropriate tubular Dacron graft is all that is needed to restore valve competence. The diameter of this graft should not exceed that of the average length of the free margins of the AV leaflets [3]. However, if the average length of the free margins of the leaflets is less than 24 mm, it is preferable to use a larger graft and reduce its diameter in the area where it is anastomosed to the aortic root, because grafts with small diameters in the ascending aorta can increase left ventricular afterload and cause heart failure.
Key featues of failed valve sparring op.. Is unreg cusp prolaps
Several authors suggested that use of the Yacoub technique in Marfan syndrome might be associated with a higher risk of reoperation for AI
David et al prefer the David to the Yacoub technique when the aortic annulus is >27Â mm in men and >25Â mm in women. They believe that the Yacoub technique provides excellent results in older patients with a normal aortic annulus.
Hanke et al suggested an annulus diameter of 28â30Â mm as a cut-off below which the Yacoub technique and above which the David technique may give a superior outcome.
Less fredom fr AI, but doesnât mean higer freddom fr reoperation
Repairing a bad cusp
Few paper about valve spar failure, ao valve stree, etc.. N the important need of sinusâŚ. They try to make sinus
illustrates the principles of the different surgical procedures. In all aortic roots, the 3 sinuses of Valsalva were resected, leaving a rim of sinus tissue of 2 mm to the fibrous ring of the cusps. For the remodeling technique, the Dacron tube was trimmed in a 3-tongue fashion for replacement of the sinuses (Figure 1, a). The graft was sewn on the remaining aortic root by using a continuous 4-0 Prolene suture (Ethicon, Norderstedt, Germany). The remodeling technique was modified by sewing the 3 tongues separately into the resected sinuses, enabling more precise matching and easier surgical handling of the sinus reconstruction (Figure 1, b). Finally, the remaining Dacron tube was sewn onto the reconstructed root at the height of the sinotubular junction. The sinus prosthesis was self-manufactured. A Dacron tube was trimmed by inserting sinus of Valsalvaâshaped pieces of the same tube into the graft for creation of the sinuses. The 3 neosinuses were inserted by turning the prosthetic material at a 90° angle to use the distensibility of the Dacron material in circumferential direction (Figure 1, c). The aortic valve was implanted into this prosthesis by using interrupted, U-shaped 4-0 Prolene sutures at the annulus in a planar fashion and a continuous 4-0 Prolene suture for attachment of the valve from inside the prosthesis. The sinus prosthesis was further modified by inserting 3 square pieces of the same graft into the tube after turning them by 90°, with no rim of the Dacron tube left at the base of the sinus (Figure 1, d). This prosthesis enables the surgeon to adapt the height of the graft to the varying heights of the commissures of the pig aortic root. The aortic valve was then inserted into the prosthesis, as described for the sinus prosthesis.
For the original reimplantation technique, the aortic valve was implanted into an untrimmed Dacron tube (Figure 1, e), as described above. For the modified reimplantation technique (Figure 1, f), a 6-mm-larger graft was downsized to the calculated diameter during the proximal anastomosis by using mattress Teflon felt-pledgeted sutures placed in a horizontal plane at the annulus. The valve was then implanted from inside the Dacron tube with 4-0 Prolene continuous sutures. At the sinotubular junction, another graft tailored to the calculated diameter was sutured to the larger proximal prosthesis.
KI.. Old, limited life expc, poor LV, unstab, anticoag, large annulus
Aortic root distensibility, expressed as diastolic-to-systolic change of area, decreased in all surgical procedures compared with that of the native aortic root (Figure 6). The cyclic changes of cross-sectional areas were significantly more pronounced for the remodeling and modified remodeling techniques and also for the sinus prosthesis at the sinotubular junction compared with the reimplantation and modified reimplantation techniques and the modified sinus prosthesis. At the commissural level, the reimplantation and the modified reimplantation techniques had the lowest values (6.0% Âą 1.6% and 3.94% Âą 1.2%, respectively). Distensibility was greater for the sinus and modified sinus prosthesis (9.2% Âą 2.6% and 10.4% Âą 4.3%, P < .02) and even more for the remodeling and modified remodeling techniques (17.2% Âą 5.1% and 17.2% Âą 6.4%, P < .01). At the sinus level, no differences were observed between the surgical procedures, and for area changes of less than 5% during the cardiac cycle, none of the techniques were distensible
Differences in distensibility between the surgical techniques could be found at the annular level. Although the reimplantation techniques and sinus prosthesis were comparable with the native root, a significant increase of annular distensibility was noted for the remodeling (9.88% Âą 5.4%, P = .026) and modified remodeling (8.71% Âą 4.3%, P = .017) techniques, as well as for the modified sinus prosthesis (8.68% Âą 2.2%, P = .009), compared with the native root (5.16% Âą 1.82%).