DOI: 10.1016/j.athoracsur.2006.04.018 2006;82:865-872 Ann Thorac Surg

Nardella, Diego Ornaghi, Roberto Gallotti, Luigi Chiariello and Roberto Di Bartolomeo Davide Pacini, Fabrizio Settepani, Ruggero De Paulis, Antonino Loforte, Saverio

Conduit: A Multicenter StudyEarly Results of Valve-Sparing Reimplantation Procedure Using the Valsalva

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Print ISSN: 0003-4975; eISSN: 1552-6259. Southern Thoracic Surgical Association. Copyright © 2006 by The Society of Thoracic Surgeons.

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arly Results of Valve-Sparing Reimplantationrocedure Using the Valsalva Conduit: Aulticenter Study

avide Pacini, MD, Fabrizio Settepani, MD, Ruggero De Paulis, MD,ntonino Loforte, MD, Saverio Nardella, MD, Diego Ornaghi, MD,oberto Gallotti, MD, Luigi Chiariello, MD, and Roberto Di Bartolomeo, MD

ardiac Surgery Department, S. Orsola-Malpighi Hospital, University of Bologna, Bologna; Cardiac Surgery Department, Istituto

linico Humanitas, Rozzano; and Cardiac Surgery Department, Tor Vergata University, Rome, Italy

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Background. This study evaluates the midterm clinicalesults of valve-preserving aortic root reconstruction byeans of a modified conduit incorporating sinuses ofalsalva.Methods. During a 5-year period, 151 patients with

neurysm of the aortic root underwent a reimplantationype of valve-sparing procedure using the Gelweavealsalva prosthesis that incorporates sinuses of Valsalva.here were 121 males (80.1%), and the mean age was 56.4

14.4 years (range, 14 to 83). Fourteen percent of theatients had Marfan syndrome and 8.6% had bicuspidortic valve. Seven patients (4.6%) suffered from acuteortic dissection. Aortic replacement was extended to therch in 14 patients (9.3%). Sixteen patients (10.6%) hadssociated cusp repair.Results. In-hospital mortality was 3.3%, and it was

ignificantly higher among patients operated on for acute

issection (p � 0.001) and in symptomatic patients

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hirurgia, Università degli studi di Bologna, Policlinico S. Orsola, Viaassarenti 9, Bologna 40138, Italy; e-mail: dpacini@hotmail.com.

2006 by The Society of Thoracic Surgeonsublished by Elsevier Inc

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III–IV New York Heart Association class; p � 0.021).ollow-up (mean, 18 months; range, 1 to 60) was 100%omplete. There were 2 late deaths. Ten patients (6.8%)ad 3 to 4� aortic regurgitation, and 8 of these required

ate aortic valve replacement. Cusp repair was associatedith a high incidence of late aortic valve replacement

p � 0.005). At 5 years, freedom from aortic valve replace-ent and freedom from grade 3 to 4 aortic insufficiencyas 90.8% � 3.3% and 88.7% � 3.6%, respectively.Conclusions. The reimplantation valve-sparing proce-

ure with the Gelweave Valsalva prosthesis providesatisfactory results for patients with aortic root aneu-ysm. Aortic cusp repair may lead to late aortic insuffi-iency. Proper leaflet evaluation is of paramount impor-ance in preventing residual valve regurgitation.

(Ann Thorac Surg 2006;82:865–72)

© 2006 by The Society of Thoracic Surgeons

he use of aortic valve-sparing operations has in-creased in the last years owing to a better under-

tanding of anatomy, function and pathology of the aorticoot. The two main surgical procedures adopted are theemodeling and the reimplantation techniques. Whilehe remodeling technique allows a certain reconstructionf the sinuses, it does not stabilize the annulus andarries an higher incidence of residual aortic insuffi-iency. Conversely, the classical reimplantation preventsrogressive annular dilatation but completely abolishes

he sinuses.In fact, the cylindrical shape of the tube has been

emonstrated to be a cause of increased stress motion ofhe valve leaflets, and it might lead to sudden cuspseterioration [1–3]. As it is well known that the sinuses ofalsalva are important in assuring normal function of theortic valve, many technical changes in the original

ccepted for publication April 3, 2006.

resented at the Forty-second Annual Meeting of The Society of Thoracicurgeons, Chicago, IL, Jan 30–Feb 1, 2006.

ddress correspondence to Dr Pacini, c/o Unità Operativa di Cardio-

eimplantation procedures have been suggested to createsort of pseudosinuses [4, 5]. In 2000, it became available

s a modified Dacron (C. R. Bard, Haverhill, Pennsylva-ia) tube, the Gelweave Valsalva graft (Vaskutek; Ren-

rewshire, Scotland), designed to recreate sinuses ofalsalva of normal shape and dimensions [6]. The advan-

ages of this conduit have been already reported [7–9],ot only for valve-sparing procedures but also in cases ofentall procedures [10]. In the current paper, we describe

he combined experience of three cardiac surgery depart-ents in the reimplantation type of valve-sparing proce-

ure using this conduit and analyze the clinical results ofhe first 151 patients.

atients and Methods

etween May 2000 and August 2005, 151 patients withneurysm of the aortic root underwent a valve-sparingperation according to reimplantation procedure usinghe Gelweave Valsalva prosthesis at S. Orsola HospitalUniversity of Bologna, Italy), at Istituto Clinico Humani-as (Rozzano, Italy), and at the Tor Vergata University of

ome (Rome, Italy). The study was approved by the

0003-4975/06/$32.00doi:10.1016/j.athoracsur.2006.04.018

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nstitutional Review Board of each institute, and in-ormed consent was obtained from all patients.

Patients’ age ranged from 14 to 83 years (mean, 56.4 �4.4). There were 121 male (80.1%) and 30 female (29.9%)atients. All patients were preoperatively evaluated with

ransthoracic or transesophageal echocardiography. An-iography was performed in patients older than 50 yearsf age or with a history of coronary artery disease. Thelinical and demographic profile of patients is describedn Table 1.

he Valsalva Grafthe peculiarity of the Valsalva graft is the possibility ofeconstructing the sinuses of Valsalva upon graft implan-ation and pressurization. The graft design has beenescribed in detail elsewhere [6]. Briefly, it is a standardacron conduit that incorporates a short segment of the

ame material with corrugation at a 90-degree angle withespect to the rest of the graft. This segment, called thekirt, has a length equal to the graft diameter, and it isesilient in the horizontal plane so that upon implanta-ion and pressurization, it will generate pseudosinuses ofalsalva. The suture joining these two sections of Dacroncts as a new sinotubular junction.

perative Proceduresardiopulmonary bypass was instituted through cannu-

ation of the right atrium and the ascending aorta. Theystemic temperature was lowered to 32°C. In patientsho had an aneurysm of the aortic arch or acute type Aissection, a peripheral cannulation, right femoral orxillary artery was preferred. In these cases, a systemicody temperature of 26°C was used, and antegradeelective cerebral perfusion was utilized during the pe-iod of circulatory arrest. Myocardial protection waschieved by antegrade infusion of cold (5°C to 10°C)rystalloid HTK solution (Custodiol; Koehler Chemie,

able 1. Clinical Data

Characteristic Value

umber of patients 151ex, male (%) 121 (80.1)ge, years (range) 56.4 � 14.4 (14–83)ypertension (%) 74 (49)oronary artery disease (%) 25 (16.6)enal insufficiency (%) 5 (3.3)arfan syndrome (%) 21 (13.9)

icuspid aortic valve (%) 13 (8.6)cute type A dissection (%) 7 (4.6)eoperation (%) 3 (2)YHA (%)I 48 (31.8)II 60 (39.7)III 37 (24.5)IV 6 (4)

YHA � New York Heart Association.

lsbach-Haenlein, Germany) or by intermittent blood o

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ntegrade cardioplegia depending on the surgeon pref-rences. The left ventricle was vented by inserting aannula through the superior right pulmonary vein.

The surgical procedure followed the steps described byavid and Feindel [11] in their original article. After the

ortic wall is excised, U stitches of Ethibond 3-0 (Ethiconnc, Johnson and Johnson Co, Somerville, NJ) are passedelow the aortic valve, at the level of the ventriculoarte-ial junction, in a circular fashion. The aortic annulus ishen measured with a standard valve sizer, and a 5-mmarger prosthetic tube is chosen (ie, if the aortic annulus

easures 25 mm, a 30-mm Valsalva conduit is used). Inase of dilated annulus, the sinotubular junction is sizednstead. In detail, once a proper leaflet coaptation isbtained by pulling and aligning on the three commis-ures, the sinotubular junction can be easily measurednd the proper size (�5 mm) of the Valsalva graft can behosen. In case of an overdilated annulus, a subcommis-ural annuloplasty is performed using pledgeted Ethi-ond 2-0 at the level of the interleaflet triangles.Once the Valsalva graft size has been selected, one

mportant step is to adapt the height of the skirt to theeight of the patients commissures (Fig 1). The key pointf the surgical technique when using a Valsalva conduit

s the correct placement of the top of the commissures athe level of the union of the skirted section and thetandard graft which represents the new ST junction.his is achieved by sizing the height of the commissures

rom the annulus to the top of the commissure. The threeommissures are usually of different heights, and the onen between the right and the left cusp is shorter. There-ore, the base of the skirt can be scalloped accordingly toompensate for this length difference. This can alsorevent the impingement of the “annular to sinus

unction.”After the annular stitches have been passed through

he graft and tied, the commissures are retrieved fromnside and are pulled at the level of the neo-sinotubularunction. Next, the valve remnants are secured to the

acron wall and the coronary buttons reattached to theorresponding sinus.

Sixteen patients (10.6%) had associated cusp repaironsisting of one or more of the following procedures:hortening of the free margin either by central plicationr by weaving a double layer of 6-0 polytetrafluoroethyl-ne suture in 11 patients; raphe resection with annularlication in 7 patients (in 2 of these, shortening of the freeargin by a double layer suture was also performed, and

n another 1, an autologous pericardium patch was uti-ized to reconstruct the leaflet where the raphe wasresent); suturing of a cusp fenestration with 6-0olypropylene suture in 3 patients.Aortic arch or hemiarch replacement was performed in

4 patients (9.3%), and in 1 case, an elephant trunkechnique was utilized. Antegrade selective cerebral per-usion was used for cerebral protection in all cases.wenty-one patients (13.9%) underwent coronary arteryypass, 10 patients (6.6%) underwent mitral valve repair

r replacement, 3 patients had atrial septal defect repair,

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nd 4 patients underwent radiofrequency ablation fortrial fibrillation. Table 2 summarizes the operative data.

ollow-Upll hospital survivors were available for follow-up at

ntervals ranging from 1 to 60 months (mean, 18). Fol-ow-up information was obtained by direct examinationr by correspondence with the patient. The date of the

ast inquiry was between May and August 2005. Everyatient had an echocardiogram at 3 and 9 months after

he operation and then every year. The degree of residualalve regurgitation was assessed semiquantitatively asollows: 0, none; 1, minimal; 2, mild; 3, moderate; 4,evere. In case of valve insufficiency of grade 3 or greater,chocardiography was repeated at shorter intervals.chocardiographic data are summarized in Table 3.

tatistical Analysistatistical analysis was performed with SPSS 11.0 statis-

ical software (SPSS, Chicago, Illinois). Continuous vari-ble were expressed as the mean � SD and were com-ared with an unpaired two-tailed t test. Categoricalariables were analyzed with a �2 test or Fisher’s exactest where appropriate. Survival analyses were calculatedsing the Kaplan-Meier actuarial technique; in addition,

reedom from grade 3 or 4 aortic insufficiency and free-om from aortic valve replacement were calculated.

able 2. Operative Data

Characteristic Value

usp repair (%) 16 (10.6)ortic arch replacement (%) 14 (9.3)Hemiarch 9 (6)Total arch 3 (2.6)Elephant trunk 1 (0.7)

ABG (%) 21 (13.9)VR/MVP (%) 10 (6.6)SD repair 3 (2)adiofrequency ablation 4 (2.6)PB time, minutes (range) 143 � 35.4 (99–373)C time, minutes (range) 119 � 24.1 (67–229)

SD � atrial septal defect; CABG � coronary artery bypassraft; CC � cross clamp; CPB � cardiopulmonary bypass;VP � mitral valve plasty; MVR � mitral valve replacement.

able 3. Echocardiographic Data

EarlyPostoperative Last Visita

rade of aortic regurgitation(%)

0–1� 104 (71.2) 95 (69.8)2� 35 (24) 39 (28.7)3� 5 (3.4) 2 (1.5)4� 2 (1.4) 0 ()

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Eight patients reoperated on during follow-up were excluded; 2 patientsied during follow-up and were excluded.

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ig 1. Techniques description: adjustment of the Valsalva graft tohe patient’s valve remnants to obtain the correct placement of theommissures at the level of the prosthesis sinotubular junction. See

ext for details.

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ubgroup comparisons were made by means of theog-rank test.

esults

arly Outcomeshere were 5 in-hospital deaths (3.3%): 2 due to multiplergan failure, 2 due to low cardiac output, and 1 due to

ntestinal ischemia. Three of these patients were oper-ted on because of acute type A aortic dissection and 2ecause of annuloaortic ectasia. In-hospital mortality wasignificantly higher among patients operated on for acuteissection (42.9% versus 1.4%; p � 0.001) and amongymptomatic patients (New York Heart Association classII to IV; 9.5% versus 0.9%; p � 0.021). One patientperated on for acute dissection had an acute severeortic insufficiency on the second postoperative day. Ateoperation, a commissural detachment causing prolapsef the left and the noncoronary cusps was found. Theatient underwent aortic valve replacement with a me-hanical valve, leaving the reimplanted aortic tissuenside the graft. Three days later, a transesophagealchocardiogram showed a malfunction of the valve dueo a mechanical leaflet blockage. This had been caused byome aortic wall tissue becoming detached from theraft. The patient underwent a third operation for totaloot replacement with a composite valved graft. Weaningrom cardiopulmonary bypass was impossible, and aiventricular assist device was implanted. The patientied 2 days later. Two other deaths occurred in patientsperated on for acute dissection with peripheral malper-usion and tamponade. They died of multiple organailure during the postoperative period because. Theourth patient was operated on for annuloaortic ectasia,ut the postoperative course was complicated by aorticissection originating from the distal anastomosis; renal

nsufficiency developed and the patient died of multiplergan failure on the 12th postoperative day. The lastatient underwent successful reimplantation proceduressociated with CABG but died of intestinal ischemiafter 12 days.Four patients required rethoracotomy for bleeding. At

ischarge, 5 patients had grade 3 and 2 patients hadrade 4 residual aortic regurgitation.

ate Outcomeshere were 2 late deaths (1.4%). The causes of death wereastric hemorrhage and multiple organ failure. Bothatients had only trivial aortic regurgitation. The 5-yearurvival for all patients was 91.2% � 3.4% (Fig 2).

Eight patients were reoperated on during follow-upnd required aortic valve replacement because of resid-al aortic regurgitation. Five of these patients had al-eady a significant valve regurgitation at the time ofischarge and were reoperated on within a period be-

ween 1 month and 20 months. Two patients had a rapidppearance of aortic valve regurgitation because of en-ocarditis in 1 case and leaflet elongation (probably due

o extreme growth spur in a marfan child) in another c

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ase. The last patient (who had a grade 2 residual valveegurgitation at the time of discharge because of un-reated leaflet prolapse) had a progressive worsening ofalve regurgitation with initial ventricular enlargement.wo patients with grade 3 residual aortic regurgitationince hospital discharge are asymptomatic with normaleft ventricular size and function and are being followedlosely by serial echocardiograms. The incidence of re-peration was significantly higher among patients whoad undergone cusp valve repair (25% versus 3%; p �.005). In fact, 4 of the reoperated patients with grade 3 toaortic insufficiency had a cusp repair procedure.At 5 years, freedom from late aortic valve replacement

nd freedom from combined grade 3/4 aortic insuffi-iency and aortic valve replacement was 90.8% � 3.3%nd 88.9% � 3.3%, respectively (Fig 3A, B). The sinuses ofalsalva were well reproduced, as shown by echocardi-graphy, in all patients (Fig 4). Some patients also under-ent other imaging modality such as computed tomog-

aphy scan, magnetic resonance imagin, or angiographyhat confirmed the echocardiographic findings (Figs 5, 6).

omment

ortic valve-sparing procedures are particularly appeal-ng for patients with aortic root dilatation because theserocedures avoid the problems of prosthetic heart valves,ut pose the problem of the long-term durability of thepared aortic valve. Residual aortic valve regurgitation ishe Achille’s heel of this type of surgical procedure.mong the two major techniques of valve-sparing pro-

edures, remodeling [12] or reimplantation [11], the latestas gained popularity in the past years because it pro-ides a better annulus stabilization, which has beenhown as an important variable in the long-term dura-ility of the result.The drawbacks of the reimplantation technique is that it

ig 2. Overall actuarial survival for all patients. Survival was3.5% at 1 year and 91.2% at 5 years.

ompletely abolishes the sinuses of Valsalva that have been

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emonstrated of paramount importance in assuring a phys-

ologic movement of the aortic leaflets and at the same timeeducing leaflet stress. For these reasons, several variationsn the original David I technique have been introduced byarious authors [4, 5, 13]. Nonetheless, the classic David Iechnique has demonstrated encouraging medium-termesults in an adult [14, 15] as well as in a Marfan [16, 17]opulation in various reports. Our preference goes to these of the Valsalva graft (Gelweave Valsalva) because it hasll the advantages of the reimplantation procedure whilellowing a proper reconstruction of the sinuses withoutignificant modification in the surgical technique. It isoped that the anatomical reconstruction that is possiblesing the Valsalva graft could contribute to a better and

onger preservation of valve integrity. It has been proved

ig 3. (A) Actuarial freedom from late aortic valve replacement.reedom from late aortic valve replacement was 95.7% at 1 year and0.8% at 5 years. (B) Actuarial freedom from combined residualrade 3-4 aortic regurgitation and aortic valve replacement. Freedomrom combined residual grade 3-4 aortic regurgitation and aorticalve replacement was 94.7% at 1 year and 88.7% at 5 years.

hat the absence of sinuses, among other factors, causes an V

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lteration in the opening and closing characteristics of thealve leaflets that could induce, with time, thickening andolling of the cusps’ free margins [1, 2].

It goes without saying that a perfect postoperativeesult with absence of residual aortic regurgitation isequired if we want to compare, in terms of long-termenefit, the positive effect of the presence of sinuses ofalsalva. Presence of more than trivial residual valve

ig 4. Postoperative echocardiographic aspect of the aortic root in aatient after a reimplantation procedure with the Valsalva graft.

ig 5. Postoperative magnetic resonance image of a Marfan syn-rome patient 3 years after aortic reimplantation procedure with the

alsalva graft.

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egurgitation is the sign of cusp malalignment, torsion,ltered coaptation, and cusp prolapse among others; allhese different anatomical factors will invariably tend to arogressive worsening with time, with the consequent

ncrease of valve insufficiency.Imperfect results, independently from the technical

r anatomical reasons that have caused them, shouldot be considered if the scope of the study is toscertain whether the presence of physiologic eddyurrents inside the reconstructed sinuses are impor-ant in preserving valve integrity in the long term. Inny case, imperfect results with more than trivialesidual valve regurgitation should not be acceptedecause the patient will face a second operation withinshort time.The initial results of this multicenter study clearly

how that an imperfect result in the immediate post-perative period should be strongly avoided. In fact,xcluding one case of endocarditis and a pediatric caseith a significant growth spur, all reoperated patientsad already evidence of grade 2 or higher aorticegurgitation at time of discharge. Furthermore, allatients were reoperated on in a period ranging from 1

o 20 months. This clearly indicates that residual aorticalve regurgitation has a tendency to worsen at a rapidace. If the postoperative transesophageal echocardio-ram shows a more than trivial valve regurgitation, it isdvisable reopen the graft and either fix the problem if

ig 6. Postoperative multislice computed tomography scan recon-truction of the entire aorta after a reimplantation procedure withhe Valsalva graft: the left and the noncoronary sinuses are clearlyetectable.

ossible or, better, immediately proceed for valve

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eplacement. Most of the failures reported are obvi-usly the consequence of our learning curve. All cen-ers did not have a previous direct experience with theeimplantation type of valve-sparing procedure, whichtarted only after the Valsalva graft became available.herefore, we must consider not only a learning curve

or the correct use of the graft but also for the surgicalrocedure itself.If other procedures are added on the valve cusps,

uch as triangular resection or plication, free-edgeeinforcement to correct an intrinsic leaflet prolapse, orcusp prolapse that has been induced by a suboptimalrientation of the valve, the chances of ending up withn imperfect result are much higher. As a matter ofact, among all patients who required an aortic valveeplacement, half of them had received some sort ofusp plasty.

On the other hand, it appears evident from thisnitial experience that a proper root and sinuses recon-truction remains stable at least for the time consid-red. It is therefore evident that only these patientshould be considered in a long-term evaluation toscertain whether the use of the Valsalva graft, withptimal sinuses reconstruction, is superior for preserv-

ng valve integrity.In conclusion, this initial experience from three differ-

nt centers has shown satisfactory midterm results.roper patient selection and correct surgical techniqueill contribute to better root reconstruction. Patients with

atisfactory reconstruction show, for the time being,table results over time.

eferences

1. Leyh RG, Schmidtke C, Sievers HH, Yacoub MH. Openingand closing characteristics of the aortic valve after differenttypes of valve-preserving surgery. Circulation 1999;100:2153–60.

2. Grande-Allen KJ, Cochran RP, Reinhall PG, KunzelmannKS. Re-creation of sinuses is important for sparing the aorticvalve: a finite element study. J Thorac Cardiovasc Surg2000;119:753–63.

3. Bellhouse BJ, Bellhouse F, Abbot JA, et al. Mechanism ofvalvular incompetence in aortic sinus dilatation. CardiovascRes 1973;7:490–4.

4. David TE, Armstrong S, Ivanov J, Feindel CM, Omran A,Webb G. Results of aortic valve-sparing operations. J ThoracCardiovasc Surg 2001;122:39–46.

5. Demers P, Craig Miller D. Simple modification of“T.David-V” valve-sparing aortic root replacement to creategraft pseudosinuses. Ann Thorac Surg 2004;78:1479–81.

6. De Paulis R, De Matteis GM, Nardi P, Scaffa R, Colella D,Chiariello L. A new aortic Dacron conduit for surgicaltreatment of aortic root pathology. Ital Heart J 2000;1:457–63.

7. De Paulis R, De Matteis GM, Nardi P, Scaffa R, Buratta M,Chiariello L. Opening and closing characteristics of theaortic valve after valve sparing procedures using a newaortic root conduit. Ann Thorac Surg 2001;72:487–94.

8. De Paulis R, De Matteis GM, Nardi P, Scaffa R, Bassano C,Chiariello L. Analysis of valve motion after the reimplan-tation type of valve-sparing procedure (David I) with anew aortic root conduit. Ann Thorac Surg 2002;74:53–7.

9. Bethea BT, Fitton TP, Alejo DE, et al. Results of aortic

valve-sparing operations: experience with remodelling and

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reimplantation procedures in 65 patients. Ann Thorac Surg2004;78:767–72.

0. De Paulis R, Tomai F, Bertoldo F, et al. Coronary flow charac-teristics after a Bentall procedure with or without sinuses ofValsalva. Eur J Cardiothorac Surg 2004;26:66–72.

1. David TE, Feindel M. An aortic valve sparing operation forpatients with aortic incompetence and aneurysm of theascending aorta. J Thorac Cardiovas Surg 1992;103:617–22.

2. Yacoub MH, Fagan A, Stassano P, et al. Results of valveconserving operations for aortic regurgitation. Circulation1983;68:311–21.

3. Cochran RP, Kunzelman KS, Eddy AC, Hofer BO, VerrierED. Modified conduit preparation creates a pseudosinus inan aortic valve-sparing procedure for aneurysm of the as-

cending aorta. J Thorac Cardiovasc Surg 1995;109:1049–58.

qually divided between 2� and 3�.

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4. David TE, Ivanov J, Armstrong S, Feindel M, Webb GD.Aortic valve-sparing operations in patients with aneurysmsof the aortic root or ascending aorta. Ann Thorac Surg2002;74(Suppl):1758–61.

5. Schäfers H-J, Fries R, Langer F, Nikoloudakis N, Graeter T,Grundmann U. Valve-preserving replacement of the as-cending aorta: remodeling versus reimplantation. J ThoracCardiovasc Surg 1998;116:990–6.

6. Miller DC. Valve-sparing aortic root replacement in patientswith the Marfan syndrome. J Thorac Cardiovasc Surg 2003;125:773–8.

7. Oliveira NC, David TE, Ivanov J, et al. Results of surgery foraortic root aneurysm in patients with Marfan syndrome.

J Thorac Cardiovasc Surg 2003;125:789–96.

ISCUSSION

R JOHN S. IKONOMIDIS (Charleston, SC): What was yourethod for sizing the grafts in these patients?

R DE PAULIS: In order to choose the graft size we measure thennulus only when the annulus is not overdilated, I would sayo more than 27 mm. We size the annulus after all the lowerutures have been passed below the annulus, and then we addmm to that measure. In this way we are taking into account the

hickness of the tissue, because the graft has to go outside theoot. In case the annulus is overdilated, you need to pull the topf the commissures toward the head of the patient until youbtain a good coaptation of the three leaflets. At that point, youeasure the diameter of the sinotubular junction and still add 5m. So usually you end up always with a measure of the graft

hat is between 30 and 32 mm, for an adult population.

R IKONOMIDIS: Did you ever encounter a situation wherehe valve commissures were so high that they did not conform tohe anatomy of the graft?

R DE PAULIS: The graft is designed in a way that the skirt ofhe graft has a one-to-one proportion between its height and itsiameter. This is slightly different than the normal proportion

or the aortic root, because in the normal aortic root, the heightf the root is 70% of the diameter. So the height of the skirt islready longer than the normal proportion of the root. So for0%, I would say even 95% of the cases, it is more than enough.n case you have a very big Marfan patient with elongatedommissures, you can use the small collar just to increase theength of the skirt. Actually, in our experience, in all of theseatients, the skirt was never shorter than needed. Usually thekirt is longer than you need, so you have to make it shorter inhe majority of cases.

Originally we had two designs of this graft, one with an opennd of the skirt and the second one with a collar, because theollar was meant to attach the valve in case you wanted to do aentall procedure. But then for practical purposes, we decided

o have only one design, so in case you do not need the collar,ou just cut it out and have an open end for your graft.

R A. W. ATKINSON (Raleigh, NC): I have two questions. One,think from your first or second slide, that 40% of the patientsad severe aortic insufficiency prior to surgery, is that correct?

R DE PAULIS: About 70% of the patients had it, they were

R ATKINSON: But they had significant, we would say, aorticnsufficiency?

R DE PAULIS: Yes.

R ATKINSON: Although that was not the primary reason too the surgery? It was the size of the aorta?

R DE PAULIS: Yes, the primary reason was always the size ofhe aortic root.

R ATKINSON: Several people have suggested that the leafletseteriorate as time goes on when you have aortic insufficiency so

hat we should push for earlier operations to prevent lateegeneration after the surgery. I wondered if you could address

hat issue?And the other question was, you used it, at least in a few

nstances, for acute dissections, and most people have felt that aormal valve can be reestablished in most cases and be usedather than a prosthetic root replacement, and I just wondered ifhere was a particular indication to use this than the standardrocedures?

R DE PAULIS: Regarding the last question of the aorticissections, I would say that it is true, that normally in aorticissections the valve is normal. So the failure we encountered

or the dissected cases was due to the fact that the commissuresore down. In that case, it needed to be reoperated on shortlyfter the operation. So I think the David operation in the case ofortic dissection is a good option because it avoids the need tolue all the sinuses, especially the noncoronary sinus that islways dissected. In that case, you have to make sure youaintain the right geometry, because distortion can be the only

ause of failure of this normal valve.As to your first question, of course if you operate at an earlier

tage, the results are much, much better. In all these failures, youill notice that most of the cases had already 3� aortic regur-itation at discharge. So that means basically a bad patientelection and also depends of the learning curve, because all ofhese centers had a learning curve either for the use of the graftut also for the reimplantation procedure, because in ourountry, the number of reimplantation procedures clearlytarted with the availability of this graft. So it is difficult,specially in the beginning of the experience, to judge if theeaflet is prolapsing or if the leaflet is healthy. Of course, now wenow that if you operate at a early stage with a smaller aortic

oot, the chances for you to get very healthy leaflets are much

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igher. So today I would not go for a valve-sparing procedure ifn aortic root is too large and for a long period of time.

R ATKINSON: To carry the argument, how about Marfan’satients particularly? I understand their leaflets are okay but

heir aortic wall is diseased, and since they have a high risk ofissection, would you recommend this procedure for prophy-

actic treatment of a Marfanoid root?

R DE PAULIS: Yes. Actually there now is a good amount ofata from a group in Germany, from Tirone David, even from

ohns Hopkins University, that the Marfan population, espe-ially if you get it early, is a very good population because youave very good results and very stable results. Only one badxperience we had in a Marfan child; he was operated on at thege of 13, and then the result was perfect for 1 year. He had noesidual aortic regurgitation. And then he grew up half a metern 6 months, and he went from 1� to 4�. So the valve waseplaced. At the operation, all three leaflets were elongated in aymmetric way. By putting a stitch just in the middle at theoduli of Arantii, you would see a perfectly normal valve, but all

hree leaflets were tremendously elongated. That is the only badxperience in the Marfan patient. The other ones remainedretty stable over time.

R VINCENT L. GOTT (Baltimore, MD): That was an excellentaper. I wish that Duke Cameron could be here to discuss thisaper; he is very enthusiastic about the De Paulis procedure and

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2006 by The Society of Thoracic Surgeonsublished by Elsevier Inc

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ameron’s surgical series, presented as a poster at this meeting,e has 51 patients, two thirds of them Marfan’s, and 1 of themad 4� aortic insufficiency and 6 had 2� aortic insufficiencyreoperatively. At late follow-up, there is no aortic insufficiency

n any of the 51 patients; all 51 are alive and the overall resultsave been excellent. Maybe you commented on this and Iissed it, but what was the relationship between preoperative

ortic insufficiency and those patients who had significant lateortic insufficiency?

R DE PAULIS: Actually, I am aware, I watched the poster fromr Cameron, and it does reflect his experience not only in thearfan population but also with that type of valve-sparing

rocedure, because the most important thing is just selection ofatients. I watched, and out of those 51 patients that he pre-ented in his poster, the majority had only 1 or 2� aorticnsufficiency, and the diameter of the root was not so big. That isery, very important to get a good result and also a long-lastingesult.

Actually, I didn’t say it, but most of the patients who hadesidual valve regurgitation had already very large root andevere, 3 or 4�, aortic regurgitation. At the time of the initialxperience, the most difficult part was, first, to judge if the leafletas prolapsing, and second, to establish the right height of the

oaptation, because it is especially difficult to judge in a cranio-audal prospection the level of the leaflets. And so if they are noterfectly on the same plane, one—even if it is not prolapsed—ill go a little bit at a lower level, and then we will get some

as used it almost exclusively for the last 2 years. In Dr residual regurgitation.

otice From the American Board of Thoracic Surgeryegarding Trainees and Candidates for Certification Whore Called to Military Service Related to the War on

he Board appreciates the concern of those who haveeceived emergency calls to military service. They may bessured that the Board will exercise the same sympatheticonsideration as was given to candidates in recognition ofheir special contributions to their country during theietnam conflict and the Persian Gulf conflict with regard

f you have any questions about how this might affectou, please call the Board office at (312) 202-5900.

arolyn E. Reed, MDhair

he American Board of Thoracic Surgery

Ann Thorac Surg 2006;82:872 • 0003-4975/06/$32.00

by on August 20, 2009 s.org

DOI: 10.1016/j.athoracsur.2006.04.018 2006;82:865-872 Ann Thorac Surg

Nardella, Diego Ornaghi, Roberto Gallotti, Luigi Chiariello and Roberto Di Bartolomeo Davide Pacini, Fabrizio Settepani, Ruggero De Paulis, Antonino Loforte, Saverio

Conduit: A Multicenter StudyEarly Results of Valve-Sparing Reimplantation Procedure Using the Valsalva

& ServicesUpdated Information

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