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A New Simple and Objective Method for Graft Sizing in Valve-Sparing Root Replacement Using the Reimplantation Technique
A New Simple and Objective Method for Graft Sizing in Valve-Sparing Root Replacement Using the Reimplantation Technique Laurent de Kerchove, MD, Munir Boodhwani, MD, MMSc, David Glineur, MD, Philippe Noirhomme, MD, and Gebrine El Khoury, MD Divisions of Cardiothoracic and Vascular Surgery, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; and Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
The methods of graft sizing in valve-sparing surgery are criticized for their complexity and subjectivity in application. We propose a simple method for graft sizing in valve-sparing root replacement using the reimplantation technique. Practically, the height of the commissure between the noncoronary cusp and the left coronary cusp give the size of the graft. This new method of graft sizing
was successfully applied in the last 27 consecutive patients with good immediate results. Graft sizing with this objective and reproducible simple method results in restoration of normal aortic valve geometry and function.
N
in the setting of root aneurysms, the height of the commissure remains relatively constant. The height of the commissure is most easily measured at the noncoronary/left coronary commissure by first drawing a connecting line between the nadirs of the 2 adjacent cusps (base of interleaflet triangle) and measuring the distance between this line and the top of the commissure. This measurement corresponds to the size of the graft chosen. When this measurement does not correspond to a labeled graft size, the next larger size graft is chosen. Although this technique can be applied for use with any type of graft, this principle is further reinforced by the idea that in a Valsalva graft, the height of the sinus portion (skirt) of the graft is equal to its diameter (Fig 2) [5]. This method of graft sizing is consistent with our previously described approach to valve-sparing root replacement using the reimplantation technique [3]. The proximal suture line is placed at the base of the interleaflet triangle, except at the noncoronary/right coronary commissure and the right coronary/left coronary commissure where external dissection is limited by the membranous septum and ventricular muscle. The collar of the Valsalva graft is always removed. Importantly this allows the commissures to be implanted along a single plane, which corresponds to the predetermined STJ in a Valsalva graft or to a new marked STJ in a straight-tube graft.
Technique The graft-sizing technique is based on the principle that in a normally functioning aortic valve, the height of the commissure (measured from the base of the interleaflet triangle to the top of the commissure) (Fig 1) is equal to the external diameter of the STJ [4]. Although various components of the aortic root and the functional aortic annulus may dilate Accepted for publication March 8, 2011. Address correspondence to Dr de Kerchove, Service de Chirurgie Cardiovasculaire et Thoracique, Cliniques Universitaires Saint-Luc UCL, Avenue Hippocrate 10, Brussels B-1200, Belgium; e-mail: laurent.dekerchove@ uclouvain.be.
© 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Comment Results Since September 2009 we have applied this new sizing method in 27 consecutive patients undergoing aortic valve–sparing surgery using the reimplantation technique (mean patient age, 50 ⫾ 12 years; 96% men; 59% bicuspid valve; and 56% with severe preoperative aortic 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.03.015
FEATURE ARTICLES
ormal aortic valve function involves a dynamic interaction between the valve leaflets and the functional aortic annulus, which consists of the ventriculoaortic junction and the sinotubular junction (STJ). The goal of aortic valve-sparing root replacement is to restore optimal root and leaflet configuration thereby resulting in a normally functioning aortic valve. As such, choice of an appropriately sized graft is a crucial step in a valvesparing procedure. Several methods of graft sizing have been proposed, including the measurement of the average height of the cusps or estimation of the size of the STJ that corresponds with good cusp coaptation. [1–3] These methods are criticized for their complexity, subjectivity in application, and lack of reproducibility. Inspired by anatomic and echocardiographic studies of the aortic valve, complemented with our experience with the Valsalva prosthesis (Gelweave Valsalva, Vascutek Ltd, Renfrewshire, Scotland), we have developed a simple, objective, and reproducible method for selecting the optimal size graft for a valve-sparing procedure using the reimplantation technique.
(Ann Thorac Surg 2011;92:749 –51) © 2011 by The Society of Thoracic Surgeons
750
HOW TO DO IT DE KERCHOVE ET AL GRAFT SIZING IN REIMPLANTATION TECHNIQUE
Ann Thorac Surg 2011;92:749 –51
Fig 1. The commissural height (A); intraoperative exposition of noncoronary/left coronary commissure (B); ) and measure of the commissural height (C). After the Valsalva graft is tied down, the top of the commissure reaches exactly the level of the neo–sinotubular junction (D).
FEATURE ARTICLES
insufficiency). A Valsalva graft was implanted in all these patients. The mean graft size chosen was only slightly different compared with our previous experience with the Valsalva graft (n ⫽ 94) (30.7 ⫾ 2.5 mm v. 29.9 ⫾ 1.6 mm). All patients with bicuspid aortic valves (n ⫽ 16) required concomitant cusp repair. However in patients with a trileaflet aortic valve (n ⫽ 11) and nonsevere preoperative AI (n ⫽ 5), only 1 patient required cusp Fig 2. In Valsalva graft the height of built-in neoaortic sinuses (skirt) (A) is similar to the diameter of proximal and distal collars (B). The graft is shown after removal of proximal collar.)
repair, suggesting good preservation of valve anatomy and function. The relationships among aortic annulus diameter, commissural height, and choice of a prosthesis is detailed in Table 1. There were no aortic valve reexplorations for residual AI and no mortality or major complications in this cohort. Discharge transthoracic echocardiography showed no AI in 15 (54%) patients and trivial to mild AI in the remaining 13 patients (46%).
Ann Thorac Surg 2011;92:749 –51
751
HOW TO DO IT DE KERCHOVE ET AL GRAFT SIZING IN REIMPLANTATION TECHNIQUE
Patients
Aortic Valve
Preoperative Annulus Diameter (mm)
Preoperative STJ Diameter (mm)
Commissural Height (⫽ Prosthesis Size)
Postoperative Annulus Diameter (mm)
Annulus Reduction (mm)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid
27 21 26 22 27 23 27 28 28 27 22 28 33 25 28 31 24 31 30 38 30 36 23 33 30 29 29
50 42 48 52 59 52 45 48 52 44 53 43 37 34 35 26 33 33 44 51 41 38 48 40 47 37 40
28 28 30 28 34 30 28 30 28 34 28 32 32 28 30 28 28 28 34 34 32 34 30 34 30 34 34
20 18 23 21 22 21 20 21 25 22 19 22 27 20 22 22 17 24 22 27 21 22 18 23 21 23 24
7 3 3 1 5 2 7 7 3 5 3 6 6 5 6 9 7 7 8 11 9 14 5 10 9 6 5
Patients are sorted by type of aortic valve. Preoperative and postoperative diameters of the aortic valve annulus (nadir of cusp insertion) and STJ (sinotubular junction) represent intraoperative transesophageal echocardiographic measurements. Annulus reduction represents the difference between preoperative and postoperative annulus diameter.
Conclusions We propose an objective and reproducible method for graft sizing in valve-sparing root replacement procedures that relies on the individual valve anatomy. Prosthesis sizing with this simple method results in restoration of a normal aortic valve geometry and function.
References 1. Doty DB, Arcidi JM Jr. Methods for graft size selection in aortic valve-sparing operations. Ann Thorac Surg. 2000;69:648 –50.
2. Kunzelman KS, Grande KJ, David TE, Cochran RP, Verrier ED. Aortic root and valve relationships. Impact on surgical repair. J Thorac Cardiovasc Surg 1994;107:162–70. 3. Boodhwani M, de Kerchove L, El Khoury G. Aortic root replacement using the reimplantation technique: tips and tricks. Interact Cardiovasc Thorac Surg 2009;8:584 – 6. 4. De Paulis R, De Matteis GM, Nardi P, Scaffa R, Buratta MM, Chiariello L. Opening and closing characteristics of the aortic valve after valve-sparing procedures using a new aortic root conduit. Ann Thorac Surg 2001;72:487-4. 5. Labrosse MR, Beller CJ, Robicsek F, Thubrikar MJ. Geometric modeling of functional trileaflet aortic valves: development and clinical applications. J Biomech 2006;39:2665–72.
FEATURE ARTICLES
Table 1. Details of Intraoperative Measures of the Aortic Annulus, Sinotubular Junction, and Prosthesis Size
The methods of graft sizing in valve-sparing surgery are criticized for their complexity and subjectivity in application. We propose a simple method for graft sizing in valve-sparing root replacement using the reimplantation technique. Practically, the height of the commissure between the noncoronary cusp and the left coronary cusp give the size of the graft. This new method of graft sizing
was successfully applied in the last 27 consecutive patients with good immediate results. Graft sizing with this objective and reproducible simple method results in restoration of normal aortic valve geometry and function.
N
in the setting of root aneurysms, the height of the commissure remains relatively constant. The height of the commissure is most easily measured at the noncoronary/left coronary commissure by first drawing a connecting line between the nadirs of the 2 adjacent cusps (base of interleaflet triangle) and measuring the distance between this line and the top of the commissure. This measurement corresponds to the size of the graft chosen. When this measurement does not correspond to a labeled graft size, the next larger size graft is chosen. Although this technique can be applied for use with any type of graft, this principle is further reinforced by the idea that in a Valsalva graft, the height of the sinus portion (skirt) of the graft is equal to its diameter (Fig 2) [5]. This method of graft sizing is consistent with our previously described approach to valve-sparing root replacement using the reimplantation technique [3]. The proximal suture line is placed at the base of the interleaflet triangle, except at the noncoronary/right coronary commissure and the right coronary/left coronary commissure where external dissection is limited by the membranous septum and ventricular muscle. The collar of the Valsalva graft is always removed. Importantly this allows the commissures to be implanted along a single plane, which corresponds to the predetermined STJ in a Valsalva graft or to a new marked STJ in a straight-tube graft.
Technique The graft-sizing technique is based on the principle that in a normally functioning aortic valve, the height of the commissure (measured from the base of the interleaflet triangle to the top of the commissure) (Fig 1) is equal to the external diameter of the STJ [4]. Although various components of the aortic root and the functional aortic annulus may dilate Accepted for publication March 8, 2011. Address correspondence to Dr de Kerchove, Service de Chirurgie Cardiovasculaire et Thoracique, Cliniques Universitaires Saint-Luc UCL, Avenue Hippocrate 10, Brussels B-1200, Belgium; e-mail: laurent.dekerchove@ uclouvain.be.
© 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Comment Results Since September 2009 we have applied this new sizing method in 27 consecutive patients undergoing aortic valve–sparing surgery using the reimplantation technique (mean patient age, 50 ⫾ 12 years; 96% men; 59% bicuspid valve; and 56% with severe preoperative aortic 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.03.015
FEATURE ARTICLES
ormal aortic valve function involves a dynamic interaction between the valve leaflets and the functional aortic annulus, which consists of the ventriculoaortic junction and the sinotubular junction (STJ). The goal of aortic valve-sparing root replacement is to restore optimal root and leaflet configuration thereby resulting in a normally functioning aortic valve. As such, choice of an appropriately sized graft is a crucial step in a valvesparing procedure. Several methods of graft sizing have been proposed, including the measurement of the average height of the cusps or estimation of the size of the STJ that corresponds with good cusp coaptation. [1–3] These methods are criticized for their complexity, subjectivity in application, and lack of reproducibility. Inspired by anatomic and echocardiographic studies of the aortic valve, complemented with our experience with the Valsalva prosthesis (Gelweave Valsalva, Vascutek Ltd, Renfrewshire, Scotland), we have developed a simple, objective, and reproducible method for selecting the optimal size graft for a valve-sparing procedure using the reimplantation technique.
(Ann Thorac Surg 2011;92:749 –51) © 2011 by The Society of Thoracic Surgeons
750
HOW TO DO IT DE KERCHOVE ET AL GRAFT SIZING IN REIMPLANTATION TECHNIQUE
Ann Thorac Surg 2011;92:749 –51
Fig 1. The commissural height (A); intraoperative exposition of noncoronary/left coronary commissure (B); ) and measure of the commissural height (C). After the Valsalva graft is tied down, the top of the commissure reaches exactly the level of the neo–sinotubular junction (D).
FEATURE ARTICLES
insufficiency). A Valsalva graft was implanted in all these patients. The mean graft size chosen was only slightly different compared with our previous experience with the Valsalva graft (n ⫽ 94) (30.7 ⫾ 2.5 mm v. 29.9 ⫾ 1.6 mm). All patients with bicuspid aortic valves (n ⫽ 16) required concomitant cusp repair. However in patients with a trileaflet aortic valve (n ⫽ 11) and nonsevere preoperative AI (n ⫽ 5), only 1 patient required cusp Fig 2. In Valsalva graft the height of built-in neoaortic sinuses (skirt) (A) is similar to the diameter of proximal and distal collars (B). The graft is shown after removal of proximal collar.)
repair, suggesting good preservation of valve anatomy and function. The relationships among aortic annulus diameter, commissural height, and choice of a prosthesis is detailed in Table 1. There were no aortic valve reexplorations for residual AI and no mortality or major complications in this cohort. Discharge transthoracic echocardiography showed no AI in 15 (54%) patients and trivial to mild AI in the remaining 13 patients (46%).
Ann Thorac Surg 2011;92:749 –51
751
HOW TO DO IT DE KERCHOVE ET AL GRAFT SIZING IN REIMPLANTATION TECHNIQUE
Patients
Aortic Valve
Preoperative Annulus Diameter (mm)
Preoperative STJ Diameter (mm)
Commissural Height (⫽ Prosthesis Size)
Postoperative Annulus Diameter (mm)
Annulus Reduction (mm)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Tricuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid Bicuspid
27 21 26 22 27 23 27 28 28 27 22 28 33 25 28 31 24 31 30 38 30 36 23 33 30 29 29
50 42 48 52 59 52 45 48 52 44 53 43 37 34 35 26 33 33 44 51 41 38 48 40 47 37 40
28 28 30 28 34 30 28 30 28 34 28 32 32 28 30 28 28 28 34 34 32 34 30 34 30 34 34
20 18 23 21 22 21 20 21 25 22 19 22 27 20 22 22 17 24 22 27 21 22 18 23 21 23 24
7 3 3 1 5 2 7 7 3 5 3 6 6 5 6 9 7 7 8 11 9 14 5 10 9 6 5
Patients are sorted by type of aortic valve. Preoperative and postoperative diameters of the aortic valve annulus (nadir of cusp insertion) and STJ (sinotubular junction) represent intraoperative transesophageal echocardiographic measurements. Annulus reduction represents the difference between preoperative and postoperative annulus diameter.
Conclusions We propose an objective and reproducible method for graft sizing in valve-sparing root replacement procedures that relies on the individual valve anatomy. Prosthesis sizing with this simple method results in restoration of a normal aortic valve geometry and function.
References 1. Doty DB, Arcidi JM Jr. Methods for graft size selection in aortic valve-sparing operations. Ann Thorac Surg. 2000;69:648 –50.
2. Kunzelman KS, Grande KJ, David TE, Cochran RP, Verrier ED. Aortic root and valve relationships. Impact on surgical repair. J Thorac Cardiovasc Surg 1994;107:162–70. 3. Boodhwani M, de Kerchove L, El Khoury G. Aortic root replacement using the reimplantation technique: tips and tricks. Interact Cardiovasc Thorac Surg 2009;8:584 – 6. 4. De Paulis R, De Matteis GM, Nardi P, Scaffa R, Buratta MM, Chiariello L. Opening and closing characteristics of the aortic valve after valve-sparing procedures using a new aortic root conduit. Ann Thorac Surg 2001;72:487-4. 5. Labrosse MR, Beller CJ, Robicsek F, Thubrikar MJ. Geometric modeling of functional trileaflet aortic valves: development and clinical applications. J Biomech 2006;39:2665–72.
FEATURE ARTICLES
Table 1. Details of Intraoperative Measures of the Aortic Annulus, Sinotubular Junction, and Prosthesis Size