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Figure 10. The level where to position the annular sutures inside the skirt is probably the most
important individual point for the correct use of a Valsalva graft. The length of the commissural posts
(CP) are measured and compared with the skirt of the graft from the ST junction down toward the base
of the skirt. This point is marked (green arrows) to indicate the proper level where the annular sutures
need to be placed along the whole circumference. This will ensure that once the commissural posts are
stretched they will easily reach the ST junction where they will be anchored. Another curved line (red
arrows) in the shape of the sinuses can also be used as a suturing path to simplify the fixing of valve
remnants to the Dacron. (ST: sino-tubular).
Figure 11. Once the graft is securely anchored to the annulus, the excess skirt (white arrows) will lie
naturally at the base of the root and it does not need to be excised.
Nevertheless, when using the Valsalva graft some specific points need to be respected.
For reimplanting the valve inside the Valsalva conduit we followed the key steps first
described by David, but we introduced some details necessary to adapt the graft to each
“patient’s aortic valve” [61, 62]. Correct matching between native and synthetic aortic root
components relies predominantly on the selection of the correct size of the graft used to
replace the aortic root. We suggest the intraoperative measurement of the aortic annulus
(using a Hegar dilator) at the sole criterion determining the choice of prosthetic tube graft. By
adding 5 mm to the measure of the annulus, the proper conduit size is chosen [63]. As a rule
of the thumb in most of the cases a 30 mm graft is required. With an annulus of 27 mm or
greater, a 32 mm Valsalva graft is invariably chosen. Next, the skirt of the Valsalva graft (i.e.,
the section corresponding to the sinus portion of the root) is matched with the length of the
commissures. When the height of commissures matches the height of the “skirt” the whole
skirt is utilized and it is secured to the annulus to provide the annuloplasty effect. When the
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height of the commissures is shorter than the height of the “skirt,” the excess of skirt is left
out and the annular sutures are passed at the corresponding level inside the skirt
(Figure 10, 11).
In this way we guarantee that, once the aortic valve is retrieved from inside the graft, the
top of the commissures will be right at the level of the new ST junction. Once the top of the
commissure are fixed at the new ST junction the aortic valve remnants can be safely sutured
to the Dacron wall without risk of modifying the valve geometry (Figure 12, 13). Finally, the
aortic leaflets are tested for symmetry and coaptation before proceeding to cusp plication
where needed. It is very important to underline the fact that by stretching the commissural
post and fixing them at the level of the new ST junction we reproduce the skeleton of the root
by connecting two rings (annuls and ST junction) by means of three straight and rigid pillars
(the commissural posts). Sinuses will bulge only between the commissural posts ensuring the
formation of three independent pockets just like in the natural aortic root.
Figure 12. The aortic valve remnants are sutured to the skirt of the Valsalva graft by polypropylene
running suture in the same manner as the subcoronary method used to implant a stentless valve. Note
that the commissures are fixed right above the new ST junction (ie, the line connecting the skirt of the
graft with the cylindrical straight portion). In this way it is possible to reconstruct the “skeleton” of the
aortic valve: the commissural posts are now stretched between 2 fixed rings (annulus and ST junction).
(ST: sino-tubular).
Figure 13. Same as in Figure 12. Reimplantation procedure for a BAV (BAV: Bicuspid Aortic Valve).
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Indications and Choice of the Strategy (Remodeling vs. Reimplantation)
AVS operations were developed to preserve the aortic valve in patients with aortic root
aneurysm with or without AR and in patients with ascending aortic aneurysm and AR
secondary to dilatation of the ST junction (in both instances we are in fact in the presence of
abnormality of the FAA with the aortic cusps reasonably normal). Over the years, the
encouraging results have allowed to expand the indication to patients with more damaged
valve leaflets (e.g., BAV and TAV with long-standing AR). The main etiologies of disease of
FAA are classically heritable disorders of connective tissue, BAV with its related aortopathy,
and arterial hypertension. All of them lead to abnormalities of the aortic wall and the
“surgical strategy” focus on the need of replacing the whole aortic wall of the root
irrespective of the type of disease in question. In this respect, the two AVS procedures are not
competitive to each other. Usually the surgeon gets acquainted with one of the two procedure
and invariably use it in all presenting cases. However, if we want to give direction based on
the specific characteristics of the two procedures we should select the reimplantation method
when the aortic annulus diameter is very large, and the remodeling method when the annular
diameter is smaller. The cut-off value varies, but it seems reasonable to consider it around 2728 mm in many cases, because long-term results after surgery worsened when this cut-off
value was exceeded [64]. Usually the size of the annulus is measured by direct intubation by
an Hegar dilatator or similar. Classically, young adults with aortic root aneurysms associated
with genetic syndromes are ideal candidates for reimplantation; others patients with
ascending aortic aneurysm and AR secondary to dilated ST junction and a normal aortic
annulus can be treated with remodeling. Through the years several modifications, some
repetitive and others innovative, have been proposed to the original reimplantation or the
remodeling procedures. Today all changes led to perform a remodeling with the addition of
annular support or a reimplantation with the creation of neo-sinuses (practically eliminating
the Achilles heels of both procedures).
It is commonly known that each surgical procedure follows a learning curve and, often,
AVS procedures have been criticized for complexity and for being time-consuming. Recently,
the group of Hannover (Germany) analyzed whether the surgeon’s level of expertise affects
the outcomes after the reimplantation procedure. The study shows a significant correlation
between the surgeon’s experience and both cardiopulmonary bypass time and aortic cross-
clamp time and a trend towards statistical significance comparing the surgeon’s skills and the
perioperative mortality and complications. Noteworthy, despite there was no association
between residual postoperative AR grade and the surgeon’s experience, there was a
significant association between aortic valve-related reoperation and the surgeon’s level of
experience [65]. Because experience is important and the learning curve could take time, it
seems reasonable to be acquainted with one of the two procedures, absorbing all “tips and
tricks.” To the same extent, it is advisable to avoid switching from one procedure to the other
before having achieved good and stable results with the procedure of your choice.
Additional Leaflets Repair (Further Scientific Contribution)
In AVS surgery the newest and more important evolution has been the development and
standardization of a technique of leaflets repair that, in addition to the graft implantation,
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could corrects residual AR due to “intrinsic” or “iatrogenic” abnormalities of the leaflets. In
many cases alteration of the geometry of the FAA (annular dilatation and/or loss of ST
junction) is the initial cause of AR that, over the time, begets cusp prolapse and leaflet
degenerative changes. In our personal experience the presence of a dilated annulus (specially
in a long-standing disease process) increases the probability of facing, at time of surgery, an
intrinsically damaged cusps. This surgical finding has been confirmed by a study using a
finite element computer-assisted stress analysis. Dilatation of ST junction was found to
slightly affect leaflet coaptation with less damage on the leaflet free margins; on the other
hand, annular dilatation, whether alone or combined with ST junction dilatation, was
responsible for a significantly reduced coaptation and a significant damage on the leaflet
structure. Data from this study indicated that the stress on the free margin and on the ‘belly’
of the aortic leaflet increased by 14% in case of isolated dilatation of the ST junction, while
increase by 67% in case of isolated annular dilatation [66]. In the clinical practice it is indeed
important, especially in young individuals with large annuli, to advise surgery at an earlier
stage in order to increase the chance of finding cusps with a relatively normal structure and
function.
Moreover, when performing an AVS procedure we invariably modify the leaflet
configuration. By removing a dilated root and replacing it with a Dacron prosthesis of
nominal normal size (average of 30 mm for an adult) we invariably reduce the root diameter
and cause some form of leaflet sagging. It has to be further emphasized that, independently on
the preferred procedure, remodeling or reimplantation, we might cause small distortion in the
valve geometry when the valve is sutured to the Dacron graft. In fact, when suturing the
Dacron to the valve remnants, attention must be paid not to distort the orientation, height and
distance of the commissures. The distortion may indeed induce leaflet prolapse that will need
to be addressed to avoid any early residual AR. It is indeed of paramount importance to
normalize not only valve geometry but also cusp configuration. Cusp configurations are
relatively difficult to standardize intraoperatively, even though these dimensions have a
mathematic relationship with sinus dimensions [67]. Schäfers et al. have designed a caliper
that facilitates easy and reproducible measurement of cusp height difference, called “effective
height” (Figure 3). The height difference of the cusp (free edge to insertion) can be measured
in millimeters and for normal tricuspid aortic valves this effective height varies from 8 to 10
millimeters [26]. In order to standardize the assessment of leaflet prolapse and cusp
configuration, the use of this caliper is recommended (using an effective height of 9-10 mm
as a reference) (Figure 4). If one cusp is found to be prolapsing (having an “effective height”
inferior to the other two cusps), the simple shortening of the leaflet’s free margin, by central
plication can eliminate the tissue redundancy and normalize cusp geometry. Employing a fine
polytetrafluoroethylene (PTFE) suture along the leaflet the free margin in order to reduce its
length is an alternative method; however, it is more difficult, less reproducible, and slightly
less accurate to perform.
At the beginning of the era of the popularity of AVS surgery additional cups intervention
after both remodeling and reimplantation have been considered a risk factor, with a
significant increase in the annual progression rate of AR [64]. In 2010 an Italian multicenter
experience of reimplantation procedure with Valsalva graft highlighted that additional aortic
leaflet repair was necessary for 9% (25 of 278 patients). At 10-years of follow-up the freedom
from aortic valve reoperation rate was 91% with an incidence of reoperation significantly
greater among patients who had undergone some form of leaflet plasty [56].
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It seemed logical that if we started with a normally functioning TAV or BAV and the
surgical procedure was only aimed at eliminating the root pathology and dilatation, the results
would have been more predictable and probably better in the long-term period. On the other
hand, when starting with a severely regurgitant aortic valve the need for valve plasty would
necessarily add another level of uncertainty. As is often the case in surgery, every surgical
additional step carries its own additional risk of failure. In this specific case the AVS
procedure combined to cusp repair would carry the correspondent risk of failure usually
associated with both procedures if considered separately. Nonetheless, leaflet plasty is
necessary if we want to spare preoperatively regurgitant valve or correcting for intraoperative alteration of leaflet geometry resulting in suboptimal coaptation and/or induced
prolapse.
With growing experience and continuing reasoning we came to the conclusion that the
combined aortic valve repair and AVS surgery are intimately linked and they always need to
be invariably part of the same procedure. Even when the valve looks normal after being reimplanted in a Dacron conduit, and even if the valve is not leaking at all after the procedure, it
is very unlikely that all the leaflet are in fact exactly at the same level (i.e., that all have the
same effective height). A not leaking valve after an AVS procedure indicates that the
coaptation length (the apposition of the leaflets) is sufficient to make the valve competent but
fails to indicate that the amount of coaptation is evenly distributed between the leaflets (i.e.,
that all leaflets have the same effective height). In fact when we perform an AVS procedure,
even in a normally functioning valve (bicuspid or tricuspid), we invariably reduce the whole
root diameter. It is common practice going from a root diameter of about 5.0/5.5 cm to a root
diameter of 30-32 mm (the two most commonly utilized sizes of Dacron conduit). The direct
and immediate effect of dramatically reducing the whole root diameter is a relative apparent
excess of tissue in the leaflet free margin that would consequently tend to prolapse. This
effect is much easily understandable when referring to a BAV configuration for its similarity
with a suspended bridge. If in a suspended bridge we move closer to the four poles that hold
the suspensions, we immediately see that the suspension will sag down. To lift the bridge to
the same level we will need to shorten the suspensions. It is evident that the induced prolapse
needs to be corrected almost invariably in both leaflets. Although this same process takes also
place for TAV, it is more difficult to immediately appreciate it because the tricuspid geometry
would better mask the induced leaflet prolapse. Even though all three leaflets might
potentially be prolapsing, usually one of the three (for some reason more frequently the right
one) would more often be affected. Furthermore, it must be stressed that, along with the
reduced root diameter, other surgical factors might be related to the modification of a leaflet
prolapse like a slightly different commissural orientation or a different tension on each
reimplanted commissure.
In simple term, when we perform an AVS procedure we invariably modify the leaflet
configuration resulting in some for of leaflet sagging and prolapsing. Although in most cases
this can be barely recognized by the naked eye, it is evident if we individually measure the
effective height with the help of a caliper. If we want to achieve a so-called “perfect
anatomical reconstruction” we need to focus not only on the root anatomy and on a proper
sinus reconstruction but also on a perfect length of the leaflet free margin that is invariably
affected by the reconstruction of the root anatomy.
After 20 years of experience we can now acknowledge that AVS surgery associated with
aortic cusp repair has further expanded its effectiveness in patients with complex aortic valve
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anatomy, avoiding aortic valve replacement and its inherent pitfalls. We can certainly state
that the road to a continuously improved reconstruction of a dilated aortic root is unraveling
and becoming clearer.
CONCLUSION
Surgical treatment of the pathology of aortic root has the aim of avoiding aortic
dissection and/or rupture while restoring normal aortic valve function. However, for a long
time, little attention had been paid to the fact that, in many circumstances, the aortic valve
was intrinsically “healthy.” Since the seminal article by H. Bentall in 1967 [68], the aortic
valve has been replaced along with the root with a valve conduit. The results are indeed
satisfactory albeit with a certain incidence of valve related complications.
In the current era, with the increasing age of patients who undergo aortic root surgery,
and data supporting the use of a biological aortic valve in the younger population, the need
for a composite biological valved conduit have significantly increased. Parallel to the
increased use of biological valve in the context of a Bentall operation, AVS operation have
also been performed in a growing number of patients. AVS operations, both the Yacoub
“remodeling” and the David “reimplantation” have evolved and improved. The growing
acceptance and applicability of these procedures are founded on a better standardization of
the technique, a lower risk of surgical bleeding, and larger amount of data on favorable longterm results. Both procedures of remodeling and reimplantation can now provide excellent
root reconstruction and adequate clinical results in terms of valve durability. The AVS
technique offers several advantages over the Bentall procedure, such as no need for oral
anticoagulation and lifestyle adjustments [69]. Nevertheless, the age criterion in patient
selection has been debated. As experience and familiarity with these techniques increases,
AVS procedures can also be considered excellent alternative to composite conduits with
biological valve, whenever in the presence of good anatomical condition, even in elderly
patients [70].
Today the strategies and techniques for AVS operations, previously viewed as difficult
and unclear, have now been thoroughly analyzed and shared with the scientific community.
Clinical results are piling up, clearly demonstrating a very long durability of the procedure
with limited incidence of complications and without limitation in any form of physical
activity. A refined multimodal imaging enables us to evaluate the results of an anatomical
reconstruction along with the physiological function of the spared and repaired aortic valve.
The road to avoid the use of valve prostheses is becoming wider.
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09.02.
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