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J Thorac Cardiovasc Surg 2001;121:1220-1221
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Reply

Kenton J. Zehr, MD

Division of Cardiovascular Surgery
Mayo Clinic
Rochester, MN 55905

Reply to the Editor:

We appreciate the interest in our manuscriptGo 1 and the various points raised in the letter to the Editor by Urbanski. Urbanski points out that the statement that cusp stress "will reduce long-term durability of the valve cusps" is a hypothesis based only on experimental work and not backed up by clinical observations. There is little published information concerning the mechanism of clinical failure in patients having undergone a valve-preserving aortic root reconstruction. I would further hypothesize that long-term failure has more to do with the quality of the cusps and the initial accuracy of the geometrical reconstruction concerning cusp coaptation than the method of reconstruction. Indeed, successful short-term and long-term results using various reconstructive methods have been reported.Go Go 2,3 Harringer and associatesGo 4 showed that patients with poor geometrical coaptation and greater than trace aortic insufficiency had a high rate of reoperation. In our own series using various techniques, reoperation appears to be related to the need for individual cusp adjustment and amount of regurgitation present after repair. However, there is anecdotal evidence that cusp maceration can occur by contact of the cusp on the Dacron tube.Fig 1 shows the cusp of a patient presenting 17 months after a valve-preserving operation using the reimplantation technique. The cusp had several areas of maceration and a torn free margin.



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  		Fig. 1. Torn right coronary cusp of a patient with severe aortic regurgitation after an aortic valve-preserving operation.

 
Because of the experimental evidence that the presence of sinuses does result in less cusp stress, there have been several clinical attempts to recreate sinuses.Go Go Go 2,5,6 Leyh and coworkersGo 7 have shown that the presence of pseudosinuses as in the remodeling technique results in nearly normal opening and closing characteristics of the aortic valve. In the evolution of the valve-preserving procedure, it makes sense that the next step is to recreate the exact anatomy of the aortic root. We believe that this sinus graft nearly does so.

Urbanski expresses some concern that the bases of the sinuses may splay out over time in this graft, resulting in progressive aortic insufficiency. Long-term results are necessary to prove or disprove this concern. It is a theoretical possibility. However, the outer purse string of the graft sinuses is incorporated in the proximal scalloped suture line. This serves to fix the anulus with a crown-shaped annuloplasty stitch that will prevent dilatation at the annular and sinus levels. In patients with a dilated anulus, an annuloplasty suture and the addition of an annular fixation strip can be performed.

The concept of individual reconstruction of the sinuses of Valsalva with single patches and the addition of a tube graft to a new sinotubular junction is interesting. We could do the same with the sinus graft. This would allow the option to use various sized neo-sinuses in the same patient. However, this would result in some additional crossclamp time. To avoid this, we choose to prepare various sized grafts in advance with equal neo-sinuses and pull them off the shelf much as one chooses a tube graft to tailor for the reimplantation or remodeling approach. Although the sinus graft as presented in our article will not work for patients with bicuspid valves or patients with an aortic dissection who do not require replacement of all sinuses, it can be used for most patients with tricuspid morphology. With the advent of 3-dimensional echocardiography, further advances in preoperative graft tailoring will be possible.

12/8/113932doi:10.1067/mtc.2001.113932

References

  1. Zehr KJ, Thubrikar MJ, Gong GG, Headrick JR, Robicsek F. Clinical introduction of a novel prosthesis for valve-preserving aortic root reconstruction for annuloaortic ectasia. J Thorac Cardiovasc Surg 2000;120:692-8.[Abstract/Free Full Text]
  2. Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg 1998;115:1080-90.[Abstract/Free Full Text]
  3. David TE, Armstrong S, Ivanov J, Webb GD. Aortic valve sparing operations: an update. Ann Thorac Surg 1999;67:1840-2.[Abstract/Free Full Text]
  4. Harringer W, Pethig K, Hagl C, Meyer GP, Haverich A. Ascending aortic replacement with aortic valve reimplantation. Circulation 1999;100(19 Suppl):II-24-8.
  5. Cochran RP, Kunzelman KS, Eddy AC, Hofer BO, Verrier ED. Modified conduit preparation creates a pseudosinus in an aortic valve-sparing procedure for aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1995;109:1049-57.
  6. David TE. Commentary. J Thorac Cardiovasc Surg 2000;119:762-3.[Free Full Text]
  7. Leyh RG, Schmidtke C, Sievers HH, Yacoub MH. Opening and closing characteristics of the aortic valve after different types of valve-preserving surgery. Circulation 1999;100:2153-60.[Abstract/Free Full Text]



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