MMCTS
(November 29, 2005). doi:10.1510/mmcts.2004.000992
Copyright © 2005 European Association for Cardio-thoracic Surgery
Procedure
The Valsalva graft in aortic valve repair and replacement
Ruggero De Paulis1,*,
Raffaele Scaffa,
Stefano Forlani and
Luigi Chiariello
Department of Cardiac Surgery, University of Tor Vergata, Cattedra di Cardiochirurgia Policlinico Tor Vergata, via Oxford 81, 00133 Rome, Italy
* Corresponding author: * Tel.: +39-06-2090 3584. E-mail: depauli{at}tin.it
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Summary
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Presentation of the use of the new Valsalva graft that incorporates sinuses of Valsalva: its use is mostly recommended for the reimplantation type of valve sparing procedure where it combines the advantages of proper anatomical reconstruction with those of annular stabilization. Its advantages when used in the remodeling technique or in a classical Bentall procedure are also shown. The problem of graft sizing and of proper geometrical reconstruction of the aortic root are addressed.
Key Words: Aortic root • Aortic valve sparing • Bentall procedure
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Introduction
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History
The composite graft replacement and coronary artery reimplantation known as Bentall operation [1] is the technique of choice for all patients with aneurysm of the ascending aorta involving the aortic root. After a composite valved graft is sutured in place the ostia of the coronary arteries are reattached to the Dacron graft either directly or by means of the ‘open’ technique known as the Carrel button [2]. In the early 1990s, Yacoub described a valve sparing aortic root remodeling for those cases with non-diseased aortic leaflets. In this technique the Dacron conduit is tailored to fit the crescent shape of the aortic annulus [3] (Schematic 1).
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Schematic 1 Classic remodeling procedure (Reproduced from Ref. [3] with permission from Elsevier Inc.). Ascending aortic aneurysm and dilated sinuses have been excised and the coronary buttons prepared. The Dacron conduit is tailored and sutured to the valve remnants.
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In the same period, David [4] introduced an alternative approach called the reimplantation technique, where the aortic valve is spared and integrated within a Dacron graft (Schematic 2).
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Schematic 2 Classic reimplantation procedure (Reproduced from Ref. [4] with permission from Elsevier Inc.). After excising the diseased aortic wall and sinuses a series of U-stitches are passed below the aortic annulus. The aortic valve is then inserted and sutured inside a standard straight Dacron conduit.
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Both techniques are widely used in the case of aortic root aneurysms associated with non-diseased aortic valves. Each of the two techniques has advantages and drawbacks that are still a matter of debate. The classic remodeling technique allows a good anatomical reconstruction of the sinuses of Valsalva but has a higher incidence of residual valve regurgitation. On the other hand, the classic reimplantation technique permits more stable results through annulus stabilization but completely abolishes the sinuses of Valsalva [5].
The Valsalva graft
In recent years a modified vascular Dacron graft has been designed to potentially fit all types of surgical approaches (Photo 1), eliminating some of the drawbacks of the different techniques, facilitating surgery and obtaining a normal anatomy of the reconstructed aortic root [6]. The original feature of this new Dacron graft is a self-expanding region (the skirt) obtained by a 90° rotation of the Dacron fabric corrugation with respect to the rest of the graft. The length of the skirt is equal to the graft diameter and once pressurized it expands by 25–30% of its diameter (Schematic 3).
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Photo 1 Original prototypes of the Valsalva graft showing its potential for application in most types of surgical procedures for the aortic root.
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Schematic 3 (Reproduced from Ref. [6] with permission from CEPI AIM Group). Original drawing of the Valsalva Dacron graft with the lower region with vertical pleats for reconstruction of the aortic root and the upper region with standard horizontal pleats for ascending aorta replacement.
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A small collar at the base of this modified portion completes the design (Photo 2). This modified conduit is commonly called the Valsalva graft for its ability to specifically reconstruct the sinuses of Valsalva that have been found of paramount importance in guaranteeing a normal function of the aortic leaflets. In fact, during systole the eddy currents that form inside the sinuses prevent the leaflets from impacting the aortic wall while in diastole they promote a smoother valve closure with a reduced stress on the valve leaflets [7,8]. Durability of the aortic leaflets greatly depends on a physiological function of the aortic root.
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Photo 2 Commercially available preclotted Gelweave Valsalva graft – MMCTSLink 72 – (Reproduced from De Paulis R, De Matteis GM, Nardi P, Scaffa R, Buratta MM, 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 with permission from Elsevier Inc.). The proximal collar at the base of the graft can be used for prosthetic heart valve attachment in case of Bentall procedure or trimmed/inverted for valve sparing procedures according to the surgeon preferences or surgical technique.
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Surgical technique
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The Valsalva graft in valve sparing procedures
Although the Valsalva graft can be used indifferently in both types of valve sparing procedure it is most widely used in the reimplantation procedure where it combines the advantages of sinus reconstruction typical of the remodeling procedure with annular stabilization, better support of the aortic wall and less chance of suture bleeding that are typical of the classic reimplantation procedure.
Remodeling procedure
Contrary to a standard Dacron conduit where the three tongue-shaped extensions need to be very long in order to obtain new sinuses of Valsalva, with the new conduit the length of three tongues are trimmed to perfectly fit the three sinuses (Schematic 4).
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Schematic 4 Remodeling procedure using the standard or the Valsalva graft (Reproduced from De Paulis R, De Matteis GM, Nardi P, Scaffa R, Buratta MM, 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 with permission from Elsevier Inc.). To generate sinuses with a standard Dacron graft the tongue-shaped extension (A–B) needs to be longer than the height of the valve remnants (A1–B1). Conversely, with the Valsalva graft, given its potential for circumferential expansion, the two distances can perfectly match with less chance of suture bleeding and less risk of distorting the valve geometry.
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The Valsalva graft facilitates the surgical procedure while at the same time offering a better reproduction of the normal root physiology, as also demonstrated by other authors [9] who used an original custom-made modified prosthesis with characteristics similar to the Valsalva graft (Photo 3).
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Photo 3 Schematic drawing and operative view of a custom-made modified graft that reproduces the sinuses of Valsalva (Reprinted from Ref. [9] with permission from Elsevier Inc.).
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Reimplantation procedure
The procedure is performed through a median sternotomy. Mobilization of the aortic arch and ascending aorta are done in a standard fashion (c.f.r. Turina M. Composite graft replacement in the aortic root: ‘button’ technique. doi:10.1510/MMCTS.2003.000001). The aneurysm is opened and antegrade cardioplegia is administered. The aortic leaflets are analyzed to verify proper coaptation and intrinsic leaflet abnormality (Video 1). The aneurysm is then totally removed, the sinuses of Valsalva are excised and the coronary buttons are prepared (Video 2).
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Video 1 Analysis of the valve leaflets to assess intrinsic leaflet abnormalities and proper level of coaptation. Valve assessment is facilitated by aligning and pulling on the three commissures. By playing with the leaflets the surgeon checks if the free margins are not prolapsing into the left ventricular outflow tract (LVOT). When the valve tends to stay open it indicates that the leaflets have a good elasticity and structure.
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Video 2 The aortic sinus wall is totally removed leaving a rim of aortic wall of approximately 3–5 mm that will be needed to suture the aortic valve to the Dacron conduit. The coronary buttons are prepared with just enough aortic wall to be sutured to the newly reconstructed sinuses.
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Tissue dissection of the valve remnants should go as deep as possible in order to reach the level of the aortic annulus. Stay sutures are placed in the commissure to keep them straight.
If the free margin of one or two leaflets is prolapsing inside the ventricle a valve replacement with a classic Bentall procedure should be considered. Alternatively, methods of leaflet repair should be added to the reimplantation procedure [10]. A series of 3/0 or 4/0 polypropylene sutures are then passed below the valve (Video 3).
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Video 3 A series of U-sutures are passed in horizontal fashion below the valve taking care not to pinch the belly of the valve leaflets. Usually a series of 12 sutures are sufficient (three below each commissure and three in between).
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Next, a proper graft size is selected (Video 4). Once the graft measure has been selected the Valsalva graft is prepared (Video 5). Then, the proper length of the skirt is established (Video 6, Schematics 5 and 6). In the very rare case of commissures longer than the skirt, part of the collar can be used to extend the skirt of the Valsalva graft (Schematic 7).
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Video 4 The proper Valsalva graft diameter is selected as follows: the annulus is sized and 5 mm are then added to that measure (e.g. if a 25-mm annulus is sized a 30-mm Valsalva graft is selected); when the annulus is over-dilated (>27 mm), the ST junction must be sized instead by pulling on three commissures until valve coaptation is obtained; a Valsalva graft measuring 5 mm larger is then selected.
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Video 5 The collar of the Valsalva graft is cut out leaving only the suture that brings together the vertical pleats. This will facilitate spacing the sutures that fix the graft to the valve annulus.
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Video 6 The height of the ‘skirt’ of the Valsalva graft is compared with the height of the commissures as follows: the height of a commissure is measured from its base (corresponding to the suture passed below the annulus) up to the top and is then matched on the skirt, from the new ST junction down, to assess the proper level where to pass the annular sutures.
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Schematic 5 Adapting the Valsalva graft to the patient's anatomy (I). When the height of the commissures matches the height of the ‘skirt’ the collar is cut out and the lower row of sutures are passed at the base of the skirt. In this way the top of the commissures will reach the level of the new sino-tubular junction (the connection between the two sections of Dacron).
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Schematic 6 Adapting the Valsalva graft to the patient's anatomy (II). When the height of the commissures is shorter than the height of the ‘skirt’ the collar is cut out and the lower row of sutures are passed at the corresponding level inside the skirt. The top of the commissures will therefore be at the level of the new sino-tubular junction.
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Schematic 7 Adapting the Valsalva graft to the patient's anatomy (III). In the rare cases when the height of the commissures is longer than the height of the ‘skirt’ the collar can be utilized to secure the lower row of sutures, to increase the length of the reconstructed root and to consent that the top of the commissures reaches the level of the new sino-tubular junction.
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The sutures are then passed through the skirt at the established level and the Valsalva graft is secured to the valve annulus (Video 7). The three commissures are then fixed at the level of the graft's sino-tubular junction (Video 8). At this point valve leaflets are tested for the proper level of coaptation and symmetry. If a satisfactory geometry is attained, the valve remnants are secured to the skirt of the graft (Video 9).
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Video 7 The lower row of sutures is passed through the base of the ‘skirt’ at the established level and the Valsalva graft is then para- the sutures are tied taking care not to pinch any portion of the valve remnants. This is better obtained by pushing the three commissures inside the left ventricle while the sutures are being tied.
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Video 8 The valve remnants are retrieved from inside the graft, they are stretched and, properly spaced, are fixed at the level of the new sino-tubular junction (i.e. at the junction between the skirt and the standard graft). Please note that the excess of aortic wall above each commissure will be trimmed once the commissures are fixed in place.
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Video 9 The valve remnants are fixed to the Dacron wall corresponding to the new sinuses by three continuous 4/0 prolene running sutures starting at the nadir of each leaflet toward the top of the commissure. The three sutures are then tied at the top of each commissure. Note that since the commissures are already positioned at the level of the new sino-tubular junction, the risk of distorting the valve geometry during suturing is minimal.
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The coronary artery buttons are then re-implanted into the sinuses graft using 5–6/0 prolene with small needle starting with the left coronary artery (c.f.r. Video 15). Distal anastomosis is performed to the arch or to the ascending aorta remnants using a 4–5/0 prolene running suture in a standard fashion.
Postoperative MRI shows a good anatomical reconstruction of the aortic root (Photo 4). Valve motion inside the Valsalva graft (Video 10) appears more physiologic when compared to a standard graft (in vivo experimental data) (Video 11).
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Photo 4 Postoperative magnetic resonance imaging (MRI) of a Marfan patient 2 years after a reimplantation procedure with the Valsalva graft showing a good anatomical reconstruction of the aortic root.
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Video 10 Reimplantation procedure with the Valsalva Dacron graft. Aortic valve motion in the presence of sinuses appears close to normal. Leaflet opening and closing is synchronous and symmetric. The opening of the valve at full systole is circular. The free margins of the leaflets are always distended and do not show any major point of bending.
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Video 11 Reimplantation procedure with a standard Dacron graft. In the absence of sinuses the valve opens in an irregular triangular shape. Leaflet opening and closing is asynchronous and asymmetric. During valve closure the leaflets free margins show many wrinkles and bending. This altered valve motion might promote valve fibrosis and reduce leaflet longevity
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The Valsalva graft in Bentall procedure
Several modifications to the standard Bentall procedure have been proposed to decrease the tension on the suture between the coronary button and the Dacron graft. This is especially important in those cases where it is difficult to mobilize the coronary arteries (redo, coronary ostia calcification) or when they are widely separated [11], or in cases where the ostia are near the valve annulus (Schematic 8) [12], or in the case of coronary kinking (Schematic 9) [13].
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Schematic 8 In case of low-lying coronary ostia an inverted U-shaped flap is created in the Dacron conduit which is then reflected and sutured to an appropriately sized coronary button (Reproduced from Ref. [12] with permission from Elsevier Inc.).
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Schematic 9 In case of tension or angulations of the right coronary artery, a piece of autogenous pericardium is tailored and utilized to increase the size of the coronary button and relieve the tension (Reproduced from Ref. [13] with permission from Elsevier Inc.).
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Because of its particular shape, the use of the Valsalva graft simplifies the surgical procedure by offering:
- Decreased tension during coronary artery suturing
- Decreased tension after graft pressurization
- Increased anatomical adaptability
- Decreased potential for suture bleeding and pseudoaneurysm formation
- Easier access to the coronary anastomosis at the end of procedure.
After clamping the aorta the aneurysm is totally removed, the valve is excised and the coronary buttons isolated (Video 12). A properly sized aortic valve is selected. Next, a Valsalva graft 5 mm larger than the prosthesis size is chosen (e.g. for a 25-mm aortic valve prosthesis a 30-mm Valsalva graft).
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Video 12 The aneurysmatic aortic wall is removed and the coronary buttons are prepared with just enough aortic wall to be sutured to the Dacron. The calcified diseased aortic leaflets are removed.
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A series of interrupted 2/0 Ticron sutures (MMCTSLink 7) with pledgets are passed through the aortic annulus (Photo 5). The collar at the base of the graft is trimmed to a 5-mm length. Next, the aortic valve prosthesis and the collar of the Valsalva graft are attached together in a single-step fashion (Video 13). This composite Valsalva Dacron graft is then secured to the patient's annulus (Video 14). The coronary ostia are re-attached to the skirted portion of the Valsalva graft (Video 15). Finally, the distal end of the graft is stretched and anastomosed to the distal aorta.
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Video 13 The holder of the bioprosthetic heart valve is inserted into the Valsalva Dacron graft so that the collar of the graft and the sewing ring of the prosthetic valve are in close contact. Next, the annular sutures, properly spaced, are passed both through the sewing ring of the valve and the collar of the graft.
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Video 14 Once all sutures have been passed through, both the prosthetic valve and the Valsalva graft are parachuted down and the sutures are tied.
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Video 15 The coronary buttons are refined and re-attached to the ‘skirt’ of the Valsalva graft using a 5-0 polypropylene suture. Because this portion of the Dacron wall is resilient suturing is facilitated and without undue tension.
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When a mechanical valve is needed it is also possible to use commercially available preclotted valved conduits that incorporate the Valsalva graft; CarboSeal ValsalvaTM (MMCTSLink 2) or SJM Master HP Valved graft with Gelweave ValsalvaTM technology (MMCTSLink 3). The surgical technique is just the same but suturing together the valve-sewing ring and the collar of the Valsalva graft is avoided.
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Results
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- Classical reimplantation and remodeling procedure using standard straight Dacron conduits have both shown low operative mortality. Freedom from residual aortic regurgitation has been reported in the range of 90% at 5 and 8 years after a reimplantation procedure while it has been reported at 55% after a remodeling procedure [14,15].
- Classical reimplantation procedure has been found particularly appropriate for patients with Marfan syndrome where a 75% freedom from aortic insufficiency greater than 2+ at 10 years has been reported [16,17].
- Due to the recent introduction into clinical practice, the results of the use of the Valsalva graft are scarce but operative mortality rate, both for valve sparing and Bentall procedure, is less than 1% [18,19].
- Residual valve regurgitation after valve sparing procedure in a short-term follow-up has been reported at 87±6% [XXI National Congress of Italian Society for Cardiac Surgery. Abstract book:273] (Graph 1).
- Due to its potential for stable aortic valve function it has been also used in a pediatric Marfan population with encouraging results [20].
- Due to the good anatomical reconstruction and to the low chance of bleeding, the reimplantation procedure with the Valsalva graft has been also used in acute type A dissection.
- Long-term results are warranted.
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Graph 1 Freedom from aortic valve insufficiency (AI)  2 in a group of patients who have undergone a reimplantation procedure with the Valsalva graft at the University of Rome Tor Vergata during a short-term follow-up (mean 27 months; range 1–48).
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Footnotes
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1 Dr De Paulis designed the Valsalva graft and has a patent licensing agreement with Vascutek/Terumo – www.vascutek.com/index1.htm 
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References
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- David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617–621.[Abstract]
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- De Paulis R, De Matteis GM, Nardi P, Scaffa R, Colella DF, Chiariello L. A new aortic Dacron conduit for surgical treatment of aortic root pathology. Ital Heart J 2000;1:457–463.[Medline]
- Thubrikar MJ, Bosher LP, Nolan SP. The mechanism of opening of the aortic valve. J Thorac Cardiovasc Surg 1979;77:863–870.[Abstract]
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- Cabrol C, Pavie A, Gandjbakhch I, Villemot JP, Guiraudon G, Laughlin L, Etievent P, Cham B. Complete replacement of the ascending aorta with reimplantation of the coronary arteries. New surgical approach. J Thorac Cardiovasc Surg 1981;81:309–315.[Abstract]
- Neveux JY, Dervanian P, Folliguet TA, Mace L, Guluta V. Technical modification for anastomosis of low-lying coronary ostia in Bentall procedure. Ann Thorac Surg 1993;56:383–384.[Abstract]
- Westaby S, Katsumata T, Vaccari G. Coronary reimplantation in aortic root replacement: a method to avoid tension. Ann Thorac Surg 1999;67:1176–1177.[Abstract/Free Full Text]
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- Kallenbach K, Hagl C, Walles T, Leyh RG, Pethig K, Haverich A, Harringer W. Results of valve-sparing aortic root reconstruction in 158 consecutive patients. Ann Thorac Surg 2002;74:2026–2033.[Abstract/Free Full Text]
- de Oliveira NC, David TE, Ivanov J, Armstrong S, Eriksson MJ, Rakowski H, Webb G. Results of surgery for aortic root aneurysm in patients with Marfan syndrome. J Thorac Cardiovasc Surg 2003;125:789–796.[Abstract/Free Full Text]
- Miller DC. Valve-sparing aortic root replacement in patients with the Marfan syndrome. J Thorac Cardiovasc Surg 2003;125:773–778.[Free Full Text]
- De Paulis R, De Matteis GM, Nardi P, Scaffa R, Colella DF, Bassano C, Tomai F, Chiariello L. One-year appraisal of a new aortic root conduit with sinuses of Valsalva. J Thorac Cardiovasc Surg 2002;123:33–39.[Abstract/Free Full Text]
- De Paulis R, Bassano C, Scaffa R, Nardi P, Bertoldo F, Chiariello L. Bentall procedures with a novel valved conduit incorporating "sinuses of Valsalva". Surg Technol Int 2004;12:195–200.[Medline]
- Bethea BT, Fitton TP, Alejo DE, Barreiro CJ, Cattaneo SM, Dietz HC, Spevak PJ, Lima JAC, Gott VL, Cameron DE. Results of aortic valve-sparing operations: Experience with remodeling and reimplantation procedures in 65 patients. Ann Thorac Surg 2004;78:767–772.[Abstract/Free Full Text]
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Summary
Introduction