Sorin Solo stentless valve: extended adaptability for sinotubular junction mismatch

Stentless valve continence is affected by the implantation technique, annular symmetry and dilatation of the sinotubular junction. We tested in vitro how the Sorin Solo stentless pericardial valve adapts to a slightly dilated sinotubular junction. Stentless Sorin Solo aortic valves (25 mm) were sutured into a 32-mm Valsalva graft suspending the commissures into the expandable region of the graft. The neo-aortic root was pressurized and sinotubular junction size progressively decreased by wrapping the neocommissural ridge with Dacron rings. Direct endoscopic view and ultrasound imaging were used to observe geometry and morphology of leaflets, regurgitation, height and level of leaflets coaptation. Fresh porcine valves of the same annular size were used as controls. Solo valves had mild regurgitation at baseline, became continent at 32 mm sinotubular junction size and remained continent at any size of reduction, with optimal coaptation height and level. Porcine valves had severe regurgitation at baseline, became continent at 30 mm and showed mild insufficiency and reduction of the coaptation level at a sinotubular junction of 28 mm. The Solo valve prevents residual valve regurgitation for a wider range of sinotubular junction mismatch when compared with natural porcine valves. This extended tolerance to sinotubular junction mismatch suggests a safe use of stentless valves even in suboptimal geometry roots.     

Adjustable sinotubular junction for aortic valve reimplantation procedures

Sinotubular junction size in aortic valve reimplantation procedures is usually predetermined on the basis of mathematical calculations and intraoperative measurements. We propose a new method for aortic valve reimplantation by which intraoperative measurements can be eliminated and sinotubular junction size adjusted after cross clamp removal to fit the patient's need. Aortic valve commissures are reimplanted in the expandable skirt of a Valsalva (Vascutek, Renfrewshire, Scotland) graft to realize an oversized sinotubular junction that is subsequently reduced to the proper size by wrapping, with Dacron rings of decreasing size, the neo-sinotubular ridge under transesophageal echocardiographic guidance.     

A simple method to adapt the height of the sinotubular junction of the De Paulis Valsalva graft to the height of the patient's sinuses in David reimplantation procedure.

De Paulis and associated introduced a new aortic root conduit for valve-sparing operation. The use of this prosthesis for David I (reimplantation) procedure occasionally may be problematic when the top of the commissures, do not match the new sinotubular junction of the graft. We propose a simple method that allows to create a new sinotubular junction at the desired level in the skirt portion of the Valsalva prosthesis.     

Remodeling of aortic root by annular reconstruction and plication of sinuses of Valsalva

We describe a successful new surgical technique for aortic root aneurysm, combined aortic valve repair by annular stabilization and externally reinforced reduction aortoplasty. The aortic valve annulus is defined in size at the level of the basal ring using a prosthetic ring made of the collar of a Gelweave Valsalva vascular graft. Dilated sinuses of Valsalva are plicated from outside the aorta. The aortic root is wrapped with the Valsalva vascular graft, the distal aortic root is sutured to the vascular graft, and the aortic annulus is thus stabilized at the sinotubular junction.     

A case of combined operation of aortic valve slicing and root remodeling for ascending aortic aneurysm with aortic regurgitation]

A 56-year-old female admitted with severe back pain, and her chest computed tomography demonstrated non-dissecting sclerotic aneurysm of the ascending aorta. Aortography and echocardiography showed marked dilatation of the ascending aorta and the Valsalva sinuses resulting in disappearance of the sinotubular junction. Aortic regurgitation of grade three was, also, recognized. A combined operation of aortic valve slicing of the right and the left coronary cusps and aortic root remodeling (Yacoub's method) was successfully performed. A woven Dacron double-veloured graft (Hemashield) of 22 mm in diameter was used for reconstruction of the ascending aorta and its root. Postoperative aortography figured the new sinotubular junction and the new Valsalva-like sinus composed by the graft, and aortic regurgitation was controlled to grade one.     

Aortic root remodeling with the "cuff" technique for stentless valve implantation

Aortic root and sinotubular junction dilatation and aneurysm of ascending aorta are considered relative contra-indications to implantation of a stentless valve prosthesis, because the modified aortic geometry leads to aortic incompetence and early failure of the prosthesis. Aortic root reconstruction can be performed according to various techniques. We present a surgical technique in which a tubular graft, replacing an ascending aortic aneurysm, allows sinotubular remodeling and satisfactory implantation of a stentless prosthesis. The native aorta is inserted into the vascular prosthesis at the level of the sinotubular junction which is wrapped in order to prevent commissure spreading. Sizing of the vascular and valve prosthesis is made according to annular diameter. Since October 1999, 6 patients have been operated using this technique with good results.     

A giant unruptured aneurysm of the sinus of Valsalva together with ectasia of the left coronary artery

A sinus of Valsalva aneurysm is defined as a dilatation of the aortic sinuses, between the aortic valve annulus and the sinotubular junction. They are rare and most frequently involve the right coronary sinus. We report a case of an unruptured giant sinus of Valsalva aneurysm in a patient associated with ectasia of the left main stem and left anterior descending coronary artery. The patient was successfully treated with aortic root replacement using a biologic conduit.     

Aortic regurgitation caused by prolapsed noncoronary cusp associated with dissecting aortic aneurysm treated by placing a prosthetic graft onto the anulus: report of a case

A 70-year-old man with severe aortic regurgitation (AR) associated with dissecting aortic aneurysm underwent a radical operation. AR was thought to be due to dilated sinotubular junction and prolapsed noncoronary cusp caused by dissecting flap extended into the sinus of Valsalva. At operation, the noncoronary cusp was slightly prolapsed into the left ventricle, but all cusps were seemed to be thin and pliable. An isolated "tongue shaped" graft was placed onto the anulus of the noncoronary cusp, and a 26 mm Woven Dacron graft was used to replace the ascending aorta. Postoperative angiogram showed mild AR and improved left ventricular (LV) function. This procedure was effective to repair AR caused by prolapsed noncoronary cusp without elongation or thickening of the valve.     

Dilation of the pulmonary autograft after the Ross procedure

OBJECTIVE: Dilation of pulmonary autograft after the Ross procedure is being recognized with increasing frequency. This study was undertaken to examine the extent of this problem and factors that may be associated with it. METHODS: The clinical, operative, and echocardiographic data of 118 patients who underwent the Ross procedure were reviewed. The mean age of 79 men and 39 women was 34 +/- 9 years, range 17 to 57 years. Bicuspid or other congenital aortic valve disease was present in 81% of patients. The pulmonary autograft was sutured as a valve in the subcoronary position in 2 patients, as a root inside of the aortic root in 45, and was used for complete aortic root replacement in 71. Teflon felt was not used to buttress the proximal or the distal anastomosis of the pulmonary autograft. The diameters of the sinuses of Valsalva, aortic anulus, and sinotubular junction were measured early and late after the operation with echocardiography. The mean follow-up was 44 months. RESULTS: The diameter of the sinuses of Valsalva increased from 31.4 +/- 0.4 mm to 33.7 +/- 0.5 mm (P =.01). Analysis of covariance revealed a significant change over time in this diameter, as well as a difference between operative techniques, with replacement of the aortic root being associated with a higher risk of dilation (P =. 0006). In 13 patients the diameter ranged from 40 to 51 mm. The diameter of the aortic anulus decreased in most patients and increased in 15, but there was no interaction between these changes and the operative technique. The diameter of the sinotubular junction increased in patients who had aortic root replacement and decreased in patients who had aortic root inclusion (P =.007). Moderate aortic insufficiency developed in 7 patients, and 3 required replacement of the pulmonary autograft. All patients with moderate aortic insufficiency had dilation of the aortic anulus and/or sinotubular junction. CONCLUSIONS: Dilation of the pulmonary autograft after the Ross procedure may occur because of an intrinsic abnormality of the pulmonary root in patients with congenital aortic valve disease. The technique of aortic root replacement is associated with a higher risk of dilation of the sinuses of Valsalva and sinotubular junction than the technique of aortic root inclusion.     

Resolution of perivalvular hematoma of the Freestyle stentless aortic root bioprosthesis implanted with a subcoronary technique

The modified subcoronary technique is frequently used to implant the Freestyle aortic root bioprosthesis because of its ease. This technique is primarily associated with hematoma in the potential space between the prosthetic and native aortic walls. We report a case of resolution of perivalvular hematoma around the Freestyle valve 6 months after implantation in a patient with aneurysm of the noncoronary sinus of Valsalva. During follow-up, the patient underwent no significant changes in pressure gradient or degree of regurgitation. Although long-term results are not yet known, the subcoronary technique may be a feasible alternative for patients with aneurysms in the sinus of Valsalva to exclude it, unless the sinotubular junction and aortic annulus are intact.     

Successful reoperation for diffuse supravalvular aortic stenosis.

We reoperated for diffuse supravalvular aortic stenosis using a modified technique of patch plasty described by Brom. A 36-year-old woman admitted to our hospital with a peak systolic pressure gradient of 92 mmHg across the ascending aorta had previously undergone Doty's operation at another hospital. Aortography showed an ascending aorta diffusely stenotic from the sinotubular junction to the aortic arch. We transected the ascending aorta just above the stenotic portion and incised the proximal wall to the sinus of Valsalva. Three patches were sewn to each sinus to expand them and the ascending aorta. The pressure gradient decreased postoperatively to 11 mmHg, and we conclude that this technique sufficiently relieves diffuse supravalvular aortic stenosis.     

A method of repair for asymmetric aneurysmal dilatation of the ascending aorta

The repair technique for an ascending aortic aneurysm depends on the portion of the aorta involved. An aneurysm in which the geometry of the sinotubular junction and the distal ascending aorta is preserved has classically been treated with resection and replacement with tube graft. We report an alternate method of resection of asymmetric aneurysmal dilatation of the ascending aorta with primary end-to-end anastomosis and our results of this approach with 14 patients. This method allows for complete resection of the aneurysm and tension-free anastomosis; it requires only one suture line and theoretically reduces the risk of bleeding. The endothelial surface of the aorta is preserved without an interposed synthetic graft. This method can be performed safely and the repair is durable at intermediate-term follow-up.     

Clinical introduction of a novel prosthesis for valve-preserving aortic root reconstruction for annuloaortic ectasia

OBJECTIVE: Most patients with annuloaortic ectasia are young. They are at risk for complications related to a lifetime of anticoagulation when composite grafts containing mechanical valves are used for reconstruction. The majority of patients have near normal valve cusps. Valve-preserving techniques have been developed to maintain valve function and avoid anticoagulation. The eddy currents occurring within the sinuses of Valsalva in the natural aortic root have been shown to be important in the smooth, gradual, and gentle closure of the valve. Compliance of the sinuses is important in reducing stress in the leaflets. A novel ascending aortic prosthesis with "built in" compliant sinuses (Robicsek-Thubrikar graft) was developed for clinical aortic root replacement. METHODS: Woven Dacron tubes were used to make the prostheses. Three precisely measured square pieces were cut to make the expandable, individual sinuses. Sewing the individual neo-sinuses to a scalloped end of the Dacron tube graft created the neo-sinotubular junction and sinotubular ridge. Five patients with annuloaortic ectasia underwent valve-preserving aortic root reconstruction. RESULTS: All intraoperative transesophageal echocardiographic images after the valve-preserving procedure showed a normal appearing root with 10% radial expansion of each sinus in systole. The space between the cusps and neo-sinus wall in systole was normal. No patient has more than mild aortic regurgitation. CONCLUSIONS: Valve-preserving aortic root reconstruction with a novel Dacron prosthesis with compliant "built in" sinuses re-establishes normal aortic root geometry with near normal valve motion. This may enhance the durability of the valve-preserving operation.     

Ascending aortic aneurysms treated by cuneiform resection and end-to-end anastomosis through a ministernotomy

BACKGROUND: Ascending aortic aneurysms without dilatation of the sinuses of Valsalva are generally handled by resection and replacement with a tubular graft or by tailoring aortoplasty. We propose an alternative treatment with a direct anastomosis of the two stumps of the aorta after complete aneurysm resection through an upper J ministernotomy. PATIENTS AND METHODS: We have applied this procedure to 45 patients. Mean age was 60.2 +/- 12.1 years. Mean aneurysm diameter was 51.0 +/- 8.0 mm. The skin incision averaged 6.5 cm. Two circumferential aortotomies were made: one at the level of the sinotubular junction, the other one just below the innominate artery. The two ends of the aorta were then sutured with a 3-0 Prolene running suture. In 31 cases (61%) aorta-associated valve replacement was carried out. RESULTS: Hospital mortality was 4.4%. Mean CPB and cross-clamp times were 104 +/- 71 and 68 +/- 25 minutes respectively. Mean blood loss was 380 +/- 300 mL. Median ventilation requirement and intensive care unit stay were 17 and 21 hours. Median hospital stay was 7 days. During the follow-up period (23.7 +/- 12.3 months), 1 patient required reoperation and 2 patients died. Event-free survival is 88.4 +/- 5.7 at 44 months. The surviving patients are routinely checked with ultrasonography and angio computed tomography scan. There was a very low redilatation rate (1 patient, 2.3%) and no incidence of pseudoaneurysm. CONCLUSIONS: Complete resection of ascending aortic aneurysms with end-to-end anastomosis through an upper ministernotomy represents a feasible, safe, physiologic and cost-effective minimally invasive surgical option in cases of aneurysms with normal or nearly normal sinotubular junctions.     

Aortic root reconstruction with preservation of native aortic valve and sinuses in aortic root dilatation with aortic regurgitation.

BACKGROUND: We assessed the results of a modified technique for aortic root reconstruction including preservation of the native aortic valve and sinuses. METHODS: A modified technique for reconstruction of the aortic root was devised in which the native aortic sinuses are preserved and remodeled, the diameter of the sinotubular junction is reduced, the ventriculoaortic junction is reinforced with a Dacron prosthesis, and the coronary ostia are reimplanted. Since January 1995, this modified operative technique was performed in 13 patients with a mean age of 54 +/- 21 years. The median grade of aortic regurgitation was 3; in 10 patients it was caused by dilatation of the sinotubular junction, and 3 had additional annuloaortic ectasia. RESULTS: The aortic crossclamping time was 61 +/- 18 minutes. In-hospital mortality was 2 of 13 (15. 3%) patients, both deaths being related to complications of aortic dissection. In 1 patient aortic regurgitation increased to grade 3, necessitating aortic valve replacement. At a mean follow-up of 2.1 years, the remaining 10 patients had stable aortic valve function with a median grade of regurgitation of 1. The mean New York Heart Association functional class was 1.2. CONCLUSIONS: Aortic root reconstruction with preservation of the native aortic valve and sinuses allows symmetric reconstruction of the aortic sinuses and adaptation of the diameters of the sinotubular and ventriculoaortic junctions, thus optimizing aortic valve function. Moreover, it prevents contact of the aortic valve leaflets with the Dacron graft, which may enhance the durability of the repair.     

A four-dimensional study of the aortic root dynamics.

OBJECTIVE: Although aortic root expansion has been well studied, its deformation and physiologic relevance remain controversial. Three-dimensional (3-D) sonomicrometry (200Hz) has made time-related 4-D study possible. METHODS: Fifteen sonomicrometric crystals were implanted into the aortic root of eight sheep at each base (three), commissures (three), sinuses of Valsalva (three), sinotubular junction (three), and ascending aorta (three). In this acute, open-chest model, the aortic root geometric deformations were time related to left ventricular and aortic pressures. RESULTS: During the cardiac cycle, aortic root volume increased by mean+/-1 standard error of the mean (SEM) 33.7+/-2.7%, with 36.7+/-3.3% occurring prior to ejection. Expansion started during isovolumic contraction at the base and commissures followed (after a delay) by the sinotubular junction. At the same time, ascending aorta area decreased (-2.6+/-0.4%). During the first third of ejection, the aortic root reached maximal expansion followed by a slow, then late rapid decrease in volume until mid-diastole. During end-diastole, the aortic root volume re-expanded by 11.3+/-2.4%, but with different dynamics at each area level. Although the base and commissural areas re-expanded, the sinotubular junction and ascending aorta areas kept decreasing. At end-diastole, the aortic root had a truncated cone shape (base area>commissures area by 51.6+/-2.0%). During systole, the root became more cylindrical (base area>commissures area by 39.2+/-2.5%) because most of the significant changes occurred at commissural level (63.7+/-3.6%). CONCLUSION: Aortic root expansion follows a precise chronology during systole and becomes more cylindrical - probably to maximize ejection. These findings might stimulate a more physiologic approach to aortic valve and aortic root surgical procedures.     

Dilation of the sinotubular junction causes aortic insufficiency after aortic valve replacement with the Toronto SPV bioprosthesis.

OBJECTIVE: This study was undertaken to examine the causes of late aortic insufficiency in patients who had aortic valve replacement with the Toronto SPV bioprosthesis (St Jude Medical, Inc, St Paul, Minn). METHODS: From 1991 to 1996, 174 patients with a mean age of 63 +/- 11 years underwent aortic valve replacement with the Toronto SPV bioprosthesis and were evaluated annually by Doppler echocardiographic studies to assess valve function. The diameters of the aortic root were retrospectively measured in all patients who had aortic insufficiency and also in a random sample of 23 patients without aortic insufficiency. The mean follow-up was 5.8 years (range 4 to 9 years). RESULTS: Aortic insufficiency greater than 1+ developed in 19 patients. The diameter of the sinotubular junction increased in these patients and did not change in those without aortic insufficiency. The ratio between the diameter of the sinotubular junction and the size of the Toronto SPV bioprosthesis increased in patients who had aortic insufficiency and did not change in those without aortic insufficiency. Both 2-way analysis of covariance and analysis by a mixed linear model demonstrated a significant difference in slopes between the patients with aortic insufficiency greater than 1+ and in those without insufficiency for the ratio of the diameter of the sinotubular junction/diameter of the Toronto SPV relationships over time (aortic insufficiency. Year; P <.001). Structural valve deterioration was observed in 5 valves, and in 4 of them the sinotubular junction of the aortic root had dilated. The freedom from structural valve deterioration was 99% +/- 1% for patients without aortic insufficiency and 82% +/- 12% for those with aortic insufficiency of more than 1+ at 8 years (P =.004). One patient had moderate aortic insufficiency without structural valve deterioration and dilation of the sinotubular junction. CONCLUSIONS: Dilation of the sinotubular junction causes aortic insufficiency after aortic valve replacement with the Toronto SPV bioprosthesis and increases the risk of structural valve deterioration. Banding the sinotubular junction may prevent dilation and enhance the durability of this valve.     

Quantitative approach to aortic valve-sparing surgery

Our goal was to understand why it is difficult to achieve reliable valve competence after aortic valve-sparing surgery, and to propose quantitative data aimed at improving the outcome of the procedure. Valve-sparing procedures were performed in patients with dilated aortic roots and aortic regurgitation, and reproduced in physical models to explore what should be the restored dimensions of the aortic root and leaflets for valve sparing to be successful. In parallel, a three-dimensional geometric model of the aortic valve was tested to evaluate its capability to predict the annulus diameter, sinotubular junction diameter, valve height, and leaflet free-edge length and height in competent spared valves. Valve sparing resulted in more or less severe residual regurgitation in all the patients considered. Successful valve-sparing was achieved in vitro by making further changes to the annulus diameter, the leaflet free-edge length and/or graft size. The changes needed were effectively predicted by the geometric model. Tabulated valve dimensions allowing restoration of competence were generated for convenient use by surgeons. A quantitative approach to aortic valve sparing is proposed, putting emphasis on the functional characteristics of the restored valve geometry.     

The ideal theoretical graft oversizing in valve-sparing aortic operations with a standard tubular or a Valsalva graft

Objective: We sought to determine, by a mathematical model, the ideal theoretical degree of ascending aortic graft oversizing needed to obtain normal sinuses dimension in the reimplantation type of valve-sparing aortic operations. Methods: To define a normal-range value, size of sinuses of Valsalva was conventionally expressed as the area surrounding fully opened aortic cusps, the so-called beyond leaflets area (BLA), and measured in 50 healthy subjects. A mathematical relationship between aortic annulus diameter, aortic sinuses diameter and resulting BLA was defined. By simulating intra-operative scenarios, the effect of different degrees of a standard or Valsalva graft oversizing on BLA extension was tested. Results: The same degree of graft oversizing resulted in a bigger beyond leaflets area for the Valsalva graft than for a standard graft. Oversizing degrees exceeding +7 mm for a standard graft and +3 mm for the Valsalva graft resulted in a beyond leaflets area over normal limits. Results were expressed in a visual form as two different normograms, one for the standard graft and one for the Valsalva graft. Conclusions: A less pronounced graft oversizing is needed to achieve normal-range sinuses size when using a Valsalva graft, the ideal theoretical graft oversizing was +7 mm for a standard graft and +3 mm for the Valsalva graft, our normograms can be helpful in selecting a proper graft size when performing a valve-sparing aortic procedure.