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Originally presented as a STSA/CTSNet Surgical Motion Picture at the 2016 STSA Annual Meeting.
Objectives: Dealing with the small aortic root is always a challenging clinical problem, particularly in the reoperative setting, in which scarring and fibrosis of surrounding tissues reduces the flexibility of the left ventricular outflow tract. In this situation, it may not always be possible to implant an adequately sized new valve prosthesis, resulting in a degree of patient-prosthesis mismatch, and leading to high trans-valvular gradients postoperatively. The authors demonstrate their preferred solution for addressing this difficult condition.
Methods: The technique for negotiating the small aortic root is demonstrated in a 31-year-old female patient who underwent aortic and mitral valve replacement in the not-too-distant past, and who now presented with unacceptably high gradients across her old 17 mm mechanical aortic valve.
Results: As illustrated in the video presentation, a 23 mm mechanical aortic valve was able to be secured within a 26 mm Valsalva graft. The valve was sited within the graft in an extra-anatomic position, “floating” within the sinus segment, rather than being positioned at the level of the annulus. This allowed the authors to implant a significantly larger valve than would otherwise have been possible. Postoperatively, the patient had a peak gradient of only 12 mmHg across the new aortic prosthesis.
Conclusion: Positioning the new aortic valve in a “floating” position within the sinus segment of the aortic graft allows a significantly larger prosthesis to be implanted than would otherwise be possible based on the diameter of the aortic annulus alone. The authors suggest that surgeons consider this technique when attempting to negotiate the small aortic root.
Copyright 2016, used with permission from the Southern Thoracic Surgical Association. All rights reserved.
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3 Comments
Just a new name for the old technique which was introduced almost 2 decades ago. [Urbanski PP. Complete aortic root replacement in patients with small aortic annulus. Ann Thorac Surg 2002;73:725-9]
And originally devised and popularized by Chris Cabrol in Paris in the 1970’s and 1980’s, even using SE ball balves. Chris always sewed the valve up in the graft and used the graft alone to anchor to the annulus. Indeed, when one day this displaced the valve so high that the coronaries would not reach he came up with the “Cabrol-II manuever” (horseshoe Dacron coronary graft).
Long-term results with total
replacement of the ascending aorta
and reimplantation of the coronary
arteries. C Cabrol, A Pavie, P Mesnildrey, I Gandjbakhch, L
Laughlin, V Bors and T Corcos. JTCVS 91: 17-25, 1986.
Absolutely agree! And thereofer I refered to this original method in my paper mentioned above. My advice for youngers who don’t remeber 70`s and 80`s: more read, less write before discovering America again.