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Ann Thorac Surg 2002;74:53-57
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Analysis of valve motion after the reimplantation type of valve-sparing procedure (David I) with a new aortic root conduit

Ruggero De Paulis, MD*a, Giovanni Maria De Matteis, MDa, Paolo Nardi, MDa, Raffaele Scaffa, MDa, Carlo Bassano, MD, PhDa, Luigi Chiariello, MDa

a Department of Cardiac Surgery, University of Rome, "Tor Vergata," Rome, Italy

Accepted for publication March 2, 2002.

* Address reprint requests to Dr De Paulis, Cattedra di Cardiochirurgia, Università di Roma, "Tor Vergata," European Hospital, via Portuense 700, Roma 00149, Italy
e-mail: depauli{at}tin.it


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. The reimplantation type of valve-sparing procedure does not allow proper reconstruction of the sinuses of Valsalva. We assessed the valve motion after a reimplantation type (David I) of valve-sparing procedure using a new Dacron conduit that incorporates sinuses of Valsalva.

Methods. Nine consecutive patients undergoing an aortic valve-sparing procedure using the new conduit were studied using two-dimensional transesophageal echocardiography shortly (2 ± 1 months) after operation to determine root distensibility, expressed as percent change in radius and as pressure strain of the elastic modulus. Next, monodimensional view was used to assess valve motion in its various phases (rapid valve opening velocity, slow closing leaflet displacement, rapid valve closing velocity, maximal leaflet displacement, and leaflet displacement before valve closure). Seven healthy individuals served as control subjects.

Results. Root distensibility was reduced at the level of the annulus and sinotubular junction but was similar to control subjects at the level of the sinuses (percent change in radius, 4.1% ± 0.8% versus 4.5% ± 1.2%; pressure strain of the elastic modulus, 1,286 ± 674 g/cm2 versus 1,195 ± 628 g/cm2). Rapid valve opening (69 ± 34.4 cm/s versus 51 ± 11.9 cm/s) and closing (47.6 ± 16 cm/s versus 36.4 ± 9 cm/s) velocity as well as slow closing leaflet displacement (24% ± 4.7% versus 22.1% ± 7.9%), maximal leaflet displacement (20.1 ± 4 mm versus 22.7 ± 1.9 mm), and leaflet displacement before valve closure (15.2 ± 3 mm versus 17.6 ± 0.8 mm) were similar to control subjects.

Conclusions. The new aortic root conduit used in a reimplantation type of valve-sparing procedure allows the anatomic reconstruction of the aortic root with leaflet motion similar to that of normal subjects.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
A better understanding of aortic root pathology and the increasing incidence of aortic valve regurgitation caused by aortic root dilatation has favored the widespread use of aortic valve-sparing operations. The two main techniques adopted are the remodeling technique and the reimplantation technique in which the diseased aortic wall is replaced with a polyethylene terephthalate fiber (Dacron) conduit [1, 2]. Because of the cylindrical shape of a standard Dacron conduit, different surgical techniques have been suggested to create some sort of pseudosinuses [3–5], which are recognized to be important for proper valve motion and decreased leaflet stress [6, 7]. Recently, we introduced a modified Dacron conduit (Gelweave Valsalva, Sulzer Vascutek, Renfrewshire, Scotland) that on implantation recreates sinuses of Valsalva of normal shape and dimension [8]. We have previously shown the advantages of this new conduit over a standard conduit when used in the remodeling type of valve-sparing procedure [9]. In this study the valve motion and the compliance of the new conduit was analyzed in a group of patients undergoing a reimplantation type of valve-sparing procedure. Because the same methods were used in our previous study and in the present study, it is also possible to compare patients undergoing both types of valve-sparing procedure (remodeling and reimplantation) using the newly designed Dacron conduit.


   Patients and methods
Top
 Footnotes
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
Patient population
From May 2000, all patients with an aneurysm of the aortic root associated with aortic regurgitation without any intrinsic abnormality of the valve leaflets underwent a reimplantation procedure by means of the new aortic root conduit. The first 9 consecutive patients constitute the study group. All patients were included irrespective of age, sex, associated pathologic disease, size of the aneurysm, or degree of valve insufficiency. Seven healthy individuals without abnormalities in valve function, ventricular function, or root anatomy served as the control group. These individuals were the same control group patients that were used in a previous similar study [9]. For the sake of clarity and to facilitate comparison among patients undergoing the two different types of valve-sparing procedure, data from patients undergoing the remodeling procedure using the new conduit in our previous study have also been included in all tables and indicated as group A. Patient characteristics are indicated in Table 1. All follow-up evaluations were conducted at our hospital, and informed consent was obtained before follow-up evaluation.


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  		Table 1. Patients Characteristics

 
Graft description and surgical technique
The new graft design has been more extensively described in previous articles [8, 9]. It has a short proximal portion (the skirt of the graft) with a different compliance with regard to the rest of the graft that allows the re-creation of pseudosinuses of Valsalva on conduit pressurization. The union between the skirted section of the graft and the standard graft constitutes the new sinotubular junction. A small collar at the base of the conduit completes the design. The surgical procedure follows the steps as described by David and Feindel [2] in their original manuscript. After the aortic wall has been excised, a series of U stitches are passed below the aortic valve and outside the aortic wall remnants in a circular fashion. Next, the length of the commissural posts is matched against the length of the skirted section of the graft. Inasmuch as in most of the cases the commissural posts are shorter than the skirted section of the graft, the collar is trimmed to a minimum and the sutures are passed at the base of the skirt or a little higher so that the top of the commissures will reach the new sinotubular junction. In the rare occurrence in which the valve remnants are longer than the skirt, the collar can also be used to secure the graft to the annulus. When the proximal portion of the graft has been secured to the annulus, the three commissures are retrieved from inside. Three alignment sutures are placed in the valve above the commissures and, properly spaced, are pulled through the graft at the level of the new sinotubular junction. Next, the valve remnants are secured to the Dacron wall, and the coronary ostia are reattached to the corresponding sinus (Fig 1). The diameter of the conduit is chosen on the basis of the free margin of the leaflet, and most of the time a 30-mm diameter is used.



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  		Fig 1. Graft drawing of the new conduit in a reimplantation type of valve-sparing procedure. Dotted lines represent suturing of the patient’s own valve to the skirted section of the graft. Note that the top of the commissures reach the new sinotubular junction. After suturing of the valve is completed, the conduit can bulge only at the site of the sinuses whereas it will remain straight behind the commissural posts. Coronary artery is attached at the center of the corresponding sinus.

 
Echocardiographic measurements
Data acquisition and measurements followed the protocol described by Leyh and associates [6] and used by us in a similar study [9]. Briefly, two-dimensional transesophageal echocardiography (Hewlett-Packard Sonos 5500 system, Andover, MA) was used to measure root dimension at the level of the annulus, the sinuses of Valsalva, and the sinotubular junction. Next, the area outside the leaflets was calculated as the difference between aortic valve area and cross-sectional aortic root area at the sinuses of Valsalva traced in the same two-dimensional short-axis view frame. Using continuous and pulsed-wave Doppler signal, maximum velocity across the valve and the presence of residual aortic valve regurgitation was assessed. Finally, transesophageal M-mode echocardiography at a paper speed of 100 mm/s was used to record the motion of the aortic leaflets and to measure the following: rapid valve opening and closing time and velocity, leaflet displacement after rapid valve opening and before rapid valve closing, and slow closing leaflet displacement (Fig 2). Then the following derived variables were calculated:



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  		Fig 2. Schematic drawing of an M-mode tracing describing the measured aortic valve opening and closing features. a–b, rapid valve opening; b–c, slow systolic closure; c–d, rapid valve closing. (D1 = maximal leaflet displacement; D2 = leaflet displacement before rapid valve closing; ET = ejection time; RVCT = rapid valve closing time; RVOT = rapid valve opening time; SCD = slow closing displacement.) (Reprinted with permission from The Society of Thoracic Surgeons [Ann Thorac Surg 2001, 72, 487–94].)

 
Percent change in radius (PCR) was calculated as PCR = ({Delta}R x 100)/R, where {Delta}R indicates the difference between the largest and the smallest diameter, and R, the average diameter.

Pressure-strain elastic modulus (PSEM) was calculated as PSEM = ({Delta}P x R)/R, where {Delta}P is the difference between systolic and diastolic pressures.

Slow closing displacement (SCD) of leaflet was calculated as SCD = [(D1 - D2)/D1] x 100, where D1 indicates the maximum leaflet displacement, and D2, leaflet displacement before rapid valve closing (Fig 2). All patients were evaluated shortly after operation (average, 2 ± 1 months).

Statistical analysis
A two-way analysis of variance was used to compare continuous data among the three groups. Post hoc comparisons were made using the Scheffé F test. When the variances were not the same for each group, the appropriate nonparametric tests (Kruskal-Wallis, Mann-Whitney) were used. Categorical data were compared using the {chi}2 test. A probability value less than 0.05 was considered significant. All statistical analyses were performed with StatView (version 5.0) for Windows 8.0 (SAS Institute Inc., Cary, NC).


   Results
Top
 Footnotes
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
None of the patients died, and they were discharged from the hospital in good clinical condition. After a mean follow-up of 6 ± 3 months, all patients were in New York Heart Association class I or II. No adverse effects were reported. None of the patients was receiving anticoagulant or antiplatelet therapy. Overall the mean postoperative residual aortic regurgitation was 0.8 ± 0.6 (from grade 1 to 4). Hemodynamic characteristics of the three groups of patients at the time of echocardiographic evaluation were similar (Table 2).


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  		Table 2. Hemodynamic Measurements at Postoperative Echocardiographic Evaluation

 
Root dimension and compliance
Aortic root dimensions were similar to control group patients at the level of the annulus and ST junction, whereas they were significantly larger at the level of the sinuses. Similarly, the area between the open leaflets and the Dacron wall was larger than that of control patients. On the other hand, root distensibility, expressed either as percent change in radius or as pressure-strain of the elastic modulus, appeared to be maintained only at the level of the sinuses, whereas it was reduced both at the level of the annulus and at the level of the sinotubular junction (Table 3). Compared with patients undergoing the remodeling procedure (group A), the differences were present only at the level of the annulus in term of dimension and distensibility (Table 3).


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  		Table 3. Diastolic Root Dimension at Various Levels and Aortic Root Distensibility

 
Valve motion
There were no major differences in the opening and closing characteristics of the valve between the study group and the control group. Of note, there were very few differences in terms of leaflet displacement during the different phases of the cardiac cycle (Table 4). Only patients undergoing the remodeling procedure (group A) showed a slightly larger leaflet displacement (Table 4).


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  		Table 4. Opening and Closing Characteristics of the Valve Leaflets

 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
In the last few years many experimental studies have shown that preserving or reconstructing sinuses of Valsalva that would mimic as close as possible the natural sinuses has a profound impact on leaflet function and therefore on leaflet longevity. By reconstructing sinuses of normal shape and dimension, the overall stress and strain on the various regions of the cusps are greatly reduced [7]. On the other hand, preservation of a certain sinus compliance might prevent early tissue degeneration [10]. However, there is not as yet clinical proof to definitely confirm these theoretical assumptions.

Among the various surgical techniques proposed to re-create pseudosinuses [3–5], we have recently proposed a novel Dacron conduit that allows the reconstruction of sinuses of Valsalva in all type of aortic valve-sparing procedures [8]. Its advantages have already been shown in the setting of the remodeling type of valve-sparing procedure. Although with a standard Dacron conduit and the remodeling technique it is possible to generate a sufficient space outside the leaflets, by using the new conduit a valve motion more similar to that of the normal subject group was observed [9].

It is known that the reimplantation technique offers a better annular stabilization, a superior support of the aortic wall, and a reduced bleeding when compared with the remodeling technique, but the lack of sinuses of Valsalva or the difficulty in creating a necessary gap between the open leaflet and the wall has been a significant drawback of this technique. Of note, Leyh and colleagues [6], who first used the same protocol as in the present study, clearly demonstrated that distensibility of the aortic root and a proper valve motion were better preserved after the remodeling than after the reimplantation technique. Particularly, they showed that the reimplantation technique abolished any distensibility at all root levels (annulus, sinuses, and ST junction); the cusps took longer for closing, the slow closing displacement was significantly reduced, and the systolic contact of at least one cusp was a constant finding. The present study shows that using the same surgical technique in association with the new aortic conduit significantly improved the various measurements considered. First, the reconstruction of sinuses of normal shape and dimension assured a sufficient gap to avoid any contact between the open leaflet and the Dacron wall. Second, because of the presence of vortices inside the sinuses of Valsalva, the valve motion was similar to that of normal subjects and in particular the slow closing displacement was preserved. In fact, the slow closing displacement is a sign that the cusps began to close before flow deceleration and is strictly dependent on the presence of eddy currents inside the sinuses. Finally, a certain distensibility of the wall was preserved at the level of the sinuses. It has been demonstrated that the compliance at the sinus is important to decrease mechanical stress on the leaflet by avoiding any wrinkles on the leaflet surface during the cardiac cycle [10]. Importantly, the results of the present study are comparable with those obtained with the new prosthesis in the setting of the remodeling type of valve-sparing procedure [9], demonstrating that both techniques can now be performed equivalently with respect to a satisfactory reconstruction of the anatomy and function of the aortic root. Based on these results, we have now abandoned the remodeling technique in favor of the reimplantation technique.

The systolic contact of the open leaflet with the Dacron wall is known to be responsible for leaflet thickening, which will cause accelerated leaflet degeneration [11]. On the other hand, David and colleagues [2], who carefully avoided the possibility of any systolic contact of the leaflet and wall at the time of operation, reported a 99% freedom from reoperation and a 90% freedom from moderate aortic insufficiency after 5 years of follow-up. Nevertheless, if the valve motion inside the newly reconstructed aortic root is not physiologic and the valve shows buckling and folding on opening and closing, we could still expect a reduced leaflet longevity. It is therefore important to obtain a root reconstruction that allows a valve motion most similar to that of normal individuals.

This study demonstrates that by using this new aortic root conduit in a reimplantation type of valve-sparing procedure, the opening and closing characteristic of the spared valve tend to reproduce those of normal individuals. Overall, the use of this new graft in a reimplantation type of valve-sparing procedure should contribute to significantly enhanced valve longevity. This finding appears to be an important step toward an optimal surgical reconstitution of the anatomy and physiology of the aortic root in those patients with intrinsically normal aortic cusps.

We do not know whether the compliance of the pseudosinuses will decrease with time and whether it will negatively influence valve motion. Similarly, it is unknown whether a loss of sinus compliance could be partially compensated by larger sinuses. At the present there are not enough follow-up data on this new conduit design to answer all these questions. Nevertheless, the presence of egg-shaped sinuses and a well-defined sinotubular junction should result in a clear overall benefit in term of valve longevity.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 
Doctor De Paulis discloses that he has a financial relationship with Sulzer Vascutek, Ltd.


   References
Top
 Footnotes
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Sarsam M.A., Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc Surg 1993;105:435-438.[Abstract]
  2. David T.E., Feindel M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617-622.[Abstract]
  3. Yacoub M.H. Valve-conserving operation for aortic root aneurysm or dissection. In: Cox J.L., Sundt T.M., eds. Operative techniques in cardiac and thoracic surgery. A comparative atlas. Philadelphia: Saunders, 1996:57-67.
  4. David T.E., Armstrong S., Ivanov J., Feindel C.M., Omran A., Webb G. Results of aortic valve-sparing operations. J Thorac Cardiovasc Surg 2001;122:39-46.[Abstract/Free Full Text]
  5. Cochran R.P., Kunzelmann K.S., Eddy A.C., Hofer B.O., Verrier E.D. Modified conduit preparation creates a pseudosinus in an aortic valve-sparing procedure for aneurysm of the descending aorta. J Thorac Cardiovasc Surg 1995;109:1049-1058.
  6. Leyh R.G., Schmidtke C., Sievers H.H., Yacoub M.H. Opening and closing characteristics of the aortic valve after different types of valve-preserving surgery. Circulation 1999;100:2153-2160.[Abstract/Free Full Text]
  7. Grande-Allen K.J., Cochran R.P., Reinhall P.G., Kunzelmann K.S. Re-creation of sinuses is important for sparing the aortic valve: a finite element study. J Thorac Cardiovasc Surg 2000;119:753-763.[Abstract/Free Full Text]
  8. De Paulis R., De Matteis G.M., Nardi P., Scaffa R., Colella D., Chiariello L. A new aortic Dacron conduit for surgical treatment of aortic root pathology. Ital Heart J 2000;1:457-463.[Medline]
  9. De Paulis R., De Matteis G.M., Nardi P., Scaffa R., Buratta M., Chiariello L. Opening and closing characteristics of the aortic valve after valve sparing procedures using a new aortic root conduit. Ann Thorac Surg 2001;72:487-494.[Abstract/Free Full Text]
  10. Robicsek F., Thubrikar M.J. Role of sinus wall compliance in aortic leaflet function. Am J Cardiol 1999;84:944-946.[Medline]
  11. Zehr K.J. Valve preserving aortic root reconstruction. J Thorac Cardiovasc Surg 2001;121:1220-1221.[Free Full Text]



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