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J Thorac Cardiovasc Surg 2001;121:599-600
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Aortic valve incompetence after implantation of Freestyle stentless bioprosthesis: A technical issue?

Division of Cardiothoracic Surgery
Department of Surgery
The Chinese University of Hong Kong
Prince of Wales Hospital
Hong Kong, China

To the Editor:

We read with great interest the recent article by Kalangos and colleagues and the commentary by Westaby. ¹ In this study, the incidence of aortic incompetence was about 25% after the subcoronary implantation of the Freestyle stentless bioprosthesis (Medtronic, Inc, Minneapolis, Minn), which coincides with reports from other groups using different techniques. ^2-4 Although the degree of aortic incompetence is usually mild in the early postoperative years, such a relatively high incidence potentially can jeopardize the long-term clinical outcome. We fully agree with Westaby ¹ and others ⁴ that oversizing of the stentless valve is crucial in preventing aortic incompetence. In addition, we believe preserving the function of the native coronary sinuses and the interleaflet triangles may be equally important.

The aortic root comprises the sinuses of Valsalva, the valve leaflets, and the interleaflet triangles. The sinuses of Valsalva are considered to be the basic structural framework of the valve. Not only do they support the coronary arteries and the valve leaflets, but they also enable a competent valve closure by allowing formation of the vertices. Moreover, as suggested by Sutton, Ho, and Anderson, ⁵ the structures of the interleaflet triangles are critical for proper valvular function. Such an understanding of the functional anatomy of the aortic root is essential for the development of an appropriate technique in implanting stentless bioprostheses.

In the technique described by Kalangos and colleagues, ¹ the inflow suture line does not include the native interleaflet triangles, and the space between the prosthesis and the native subcoronary sinus wall is not completely obliterated. As discussed above, this could lead to postoperative aortic regurgitation because the competence of the Freestyle bioprosthesis depends at least in part on the supportive structures of the aortic sinuses. In fact, our view is supported by the work of Yacoub and associates ⁶ and by the reported high incidence of aortic incompetence when the Freestyle bioprosthesis is used for aortic root replacement rather than as an isolated valve prosthesis. ⁴

On the basis of such considerations, we have modified the subcoronary implantation technique by incorporating the interleaflet triangles in the inflow suture line. Instead of using glue, we apply interrupted sutures to obliterate the space between the native noncoronary sinus and the prosthesis wall. We discourage the use of glue to obliterate the interaortic space because it may change the configuration of the sinus and could lead to early and late disastrous consequence. ⁷ We have now used our technique in 15 patients and have observed no evidence of aortic incompetence after a mean follow-up of 9 months.

12/8/113011

doi:10.1067/mtc.2001.113011

References

1. Kalangos A, Trigo-Trindade P, Vala D, Panos A, Faidutti B. Aortic valve replacement with the Freestyle stentless bioprosthesis with respect to spacial orientation of patient coronary ostia [with commentary by Westaby S]. J Thorac Cardiovasc Surg 2000;119:1185-93.[Abstract/Free Full Text]
   
2. Cartier PC, Dumesnil JG, Metras J, Desaulniers D, Doyle DP, Lemieux MD, et al. Clinical and hemodynamic performance of the Freestyle aortic root bioprosthesis. Ann Thorac Surg 1999;67:345-51.[Abstract/Free Full Text]
   
3. Westaby S, Jin XY, Katsumata T, Arifi A, Braidley P. Valve replacement with a stentless bioprosthesis: versatility of the porcine aortic root. J Thorac Cardiovasc Surg 1998;116:477-84.[Abstract/Free Full Text]
   
4. Doty DB, Cafferty A, Kon ND, Huysmans HA, Krause AHJ, Westaby S. Medtronic Freestyle aortic root bioprosthesis: implant techniques. J Card Surg 1998;13:369-75.[Medline]
   
5. Sutton JP III, Ho SY, Anderson RH. The forgotten interleaflet triangles: a review of the surgical anatomy of the aortic valve. Ann Thorac Surg 1995;59:419-27.[Abstract/Free Full Text]
   
6. Yacoub MH, Kilner PJ, Birks EJ, Misfeld M. The aortic outflow and root: a tale of dynamism and crosstalk. Ann Thorac Surg 1999;68:S37-43.
   
7. Bingley JA, Gardner MA, Stafford EG, Mau TK, Pohlner PG, Tam RK, et al. Late complications of tissue glues in aortic surgery. Ann Thorac Surg 2000;69:1764-8.[Abstract/Free Full Text]
   

This Article 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): Song Wan Anthony P. C. Yim Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Arifi, A. A. Articles by Yim, A. P. C. Search for Related Content PubMed PubMed Citation Articles by Arifi, A. A. Articles by Yim, A. P. C.