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Ann Thorac Surg 2000;70:17-20
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Replacement of the aortic valve and ascending aorta with a valved stentless composite graft: technical considerations and early clinical results

^a Herz- und Gefäß-Klinik, Bad Neustadt, Germany

Address reprint requests to Dr Urbanski, Herz- und Gefäß-Klinik, Salzburger Leite 1, 97616 Bad Neustadt, Germany
e-mail: urbanski{at}kardiochirurg.de

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Replacement of the aortic valve and the ascending aorta with a conduit consisting of a mechanical valve and a Dacron tube has become a fairly common procedure. Commercially available conduits employing xenografts are rarely used for the same purpose, because if a reoperation becomes necessary due to degeneration of the valve prosthesis, usually the entire conduit must be replaced. A composite graft with a stentless valve, such as we describe in this article, avoids this problem, because in case of reoperation only the valve cusps need to be resected and the tube graft may be left in place.

Methods. Surgical technique of replacement of the aortic valve and the ascending aorta with a stentless composite graft and early results of the procedure are presented.

Results. Hemodynamics of the graft soon after surgery were excellent, with an average systolic gradient of 8 mm Hg and no regurgitation across the valve. There were two reoperations for bleeding in the early postoperative period.

Conclusions. The stentless composite graft we describe provides excellent hemodynamics, has no need for anticoagulation, and is expected to offer a benefit in case of reoperation.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Total aortic root replacement with a conduit consisting of a mechanical valve and a Dacron tube as described by Bentall and DeBono is regarded as a routine surgical method [1–5]. The use of a xenograft valve for the same purpose, which might be of benefit especially for elderly patients [6–8], is jeopardized by the possibility of late degeneration. For these cases reoperation can be difficult; because of the way in which commercially available conduits are constructed, usually the whole conduit rather than the valve alone must be replaced.

A composite graft with a stentless valve combines the benefits of the excellent hemodynamic characteristics of a stentless xenograft, which are similar to those of a homograft, and the strength and stability of the woven polyester (Dacron) vascular prosthesis commonly used for replacement of the thoracic aorta [9–12]. Moreover, the composite graft described should facilitate removal and replacement of the prosthetic valve in case of a reoperation, as it does not require replacement of the entire graft.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
From March 1998 to April 1999, 20 patients underwent replacement of the aortic valve and the ascending aorta with a valved stentless composite graft. The group included 11 men and 9 women with a mean age of 66.1 years (range, 24 to 78 years). In terms of age, a 24-year-old patient with Turner’s syndrome was the exceptional case among the otherwise elderly group. Preoperative patient characteristics are shown in Table 1. Eighteen patients had an aneurysm of the ascending aorta with a diameter of more than 5.5 cm (mean, 6.0 cm). In 2 patients dissection of the aortic wall was the indication for surgery. Table 2 shows the pathology of the aortic valve and the aortic wall among the 20 patients. There were seven concomitant procedures, all of them coronary artery bypass grafts. The bypass grafts were performed in 5 patients to address coronary heart disease and in the other 2 for the technical reason that reimplantation of the right coronary ostium did not seem feasible because of calcification of the aortic wall.

In all patients the composite graft was assembled during surgery using a stentless porcine valve (Toronto SPV, St. Jude Medical, St. Paul, MN) and a collagen-coated woven polyester vascular prosthesis (InterGard; Intervascular, La Ciotat, France). The aortic annulus was measured, and a valve prosthesis of corresponding size was selected and sutured into a vascular graft one size smaller than the valve prosthesis. When the valve size was 25, for example, a tube graft with a diameter of 24 mm was used. Ideally the outer diameter of the valve should be equal to the inner diameter of the tube graft. In reality this is not possible because valves are available in odd sizes and vascular grafts in even sizes.

In the first 6 patients the xenograft was sewn to the aortic annulus together with the tube graft using a continuous 4-0 polypropylene suture passing through both the vascular tube and the fabric covering of the prosthetic valve (Fig 1) [13]. Because of bleeding from this suture line in the remaining 14 patients, the following procedure was used: The valve was moved away from the end of the tube graft, and after it was placed inside the vascular prosthesis, its fabric covering was sewn to the tube graft with a continuous 4-0 polypropylene mattress suture leaving a 3-mm rim of tube graft below the valve. The tube graft was then anastomosed to the aortic annulus with interrupted pledgetted mattress sutures of 2-0 or 3-0 braided polyester (Fig 2). Following this the upper rim of the valve was sutured to the vascular prosthesis with a continuous 4-0 polypropylene mattress suture. The graft was then fenestrated using electric cauterization, and the coronary artery ostia were reimplanted using continuous 5-0 or 6-0 polypropylene sutures. After completion of the coronary anastomoses the tube graft was anastomosed to the distal ascending aorta with a continuous 4-0 polypropylene suture. Operative data are presented in Table 3.

View larger version (103K): [in this window] [in a new window]   Fig 1. The composite graft is sewn to the aortic annulus with a continuous suture that passes through both the vascular tube and the fabric covering of the valve prosthesis. The continuous mattress suture of the upper rim of the valve is indicated by a dotted line.

View larger version (129K): [in this window] [in a new window]   Fig 2. The composite graft is sewn to the aortic annulus with interrupted, pledgetted mattress sutures that pass through the tube graft only. The continuous mattress sutures of the lower and upper rim of the valve are indicated by dotted lines.

	Results

Top Abstract Introduction Patients and methods Results Comment References

	Comment

Top Abstract Introduction Patients and methods Results Comment References

There is no perfect device for this operation, since each of the various valved conduits available has at least one disadvantage: Conduits consisting of a mechanical valve and a Dacron tube require anticoagulation. Conduits consisting of a stented xenograft valve and a Dacron tube are difficult to exchange in case of late degeneration of the valve, since the valve and the tube graft are sutured to the aortic annulus with one common sewing ring, so that the entire conduit, rather than the valve alone, usually has to be removed when reoperation is necessary. Homografts are not readily available, tend to calcify, and are often too short for a replacement including the proximal aortic arch, a disadvantage also true for full-root xenografts.

The combination of aortic root replacement with a xenograft and replacement of the ascending aorta with a Dacron tube can cause bleeding problems at the suture line between the two components, especially when the anastomosis is performed under tension [13].

A valved composite graft, such as we have described, avoids all these problems. It needs no anticoagulation, and the valve can be readily exchanged in case of a reoperation. Calcification is limited to the valve and does not involve the tube graft, the length of the tube graft is unlimited for practical purposes, and the friable tissue of the xenograft is placed inside a Dacron tube and thereby protected from tension forces.

There is one drawback, however: The assembly of the composite graft during surgery prolongs the time of anoxic cardiac arrest. With a prefabricated composite graft the operative procedure would be similar to the implantation of a conduit with a mechanical prosthesis.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Paul P. Urbanski Robert W. Hacker Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Urbanski, P. P. Articles by Hacker, R. W. Search for Related Content PubMed PubMed Citation Articles by Urbanski, P. P. Articles by Hacker, R. W.