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Ann Thorac Surg 2002;73:728-729
© 2002 The Society of Thoracic Surgeons

Invited commentary

^a Center for Aortic Surgery and Marfan Clinic, Department of Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F25 Cleveland, OH 44195, USA

e-mail: svenssl{at}ccf.org

This report by Dr Urbanski raises two issues: first; how common is the problem of a small aortic annulus in conjunction with aortic aneurysms or dissection for which currently available prosthetic valves are too large? Secondly, could the technique of composite valve insertion described by Urbanski be of value for a patient with a small aortic root without an aortic aneurysm?

An analysis of a series of 131 composite valve graft insertions showed 18 required the smallest available valve, a size 21 prosthesis (13.7%). Results showed that the one 30-day in hospital death (0.7%) was related to bowel ischemia, not to the valve size. Of the other three deaths after discharge, one patient had a size 21 valve that was functioning well on autopsy and he had died from documented ventricular tachycardia. The other two deaths were from cirrhosis and ventricular tachycardia. Our previously reported five-year survival rate was 88.4%.

Thus, the size 21 valves appear to function well in the long term and the size 21 prostheses does not appear to be a major problem. We have noted, however, when reviewing postoperative echoes that the gradient across all composite valves appears to be greater than the equivalent "non-composite" aortic valve sizes, perhaps because of the lack of sinuses of Valsalva in the composite grafts or lack of root elasticity.

Although manufactured size 19 composite valve grafts are generally not available, we have never had to use a size 19 valve in conjunction with an aneurysm. In the rare patient with a size 19 annulus, this procedure described by Urbanski could be considered for use; however, I would recommend a homograft for an adult or a Ross procedure for a child with a concomitant aortoventricular modified Konno root enlargement for a congenital stenosis.

The second issue is whether this procedure would be of value to patients with a small annulus and no aneurysm. It is doubtful whether a root enlargement procedure is more risky. Furthermore, a deliberate excision of the midcusp annulus allows for a larger valve to be inserted. If the described procedure was used, a fairly large tube graft could be inserted with a significantly larger valve. The surgeon would have to be careful that widely spaced, horizontal mattress sutures in the left annulus do not end up narrowing the annulus with this new type of procedure rather than making it larger, particularly since there is no supporting rigid ring at the annular level. This risk of narrowing the aorta or left ventricular outflow tract we have noted can occur when doing a David aortic valve reimplantation procedure but is prevented by placing an appropriately sized Hegar’s dilator for the patient’s body surface area in the left ventricular outflow tract while tying down the sutures.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lars G. Svensson Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Svensson, L. G. Search for Related Content PubMed Articles by Svensson, L. G.