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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): Afksendiyos Kalangos Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kalangos, A. Search for Related Content PubMed Articles by Kalangos, A. Related Collections Valve disease

J Thorac Cardiovasc Surg 2001;121:600-601
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Reply

Clinic for Cardiovascular Surgery
University Hospital of Geneva
24, rue Micheli-du-Crest
1211 Geneva 14, Switzerland

Reply to the Editor:

I appreciate the interest expressed by Arifi and his colleagues in our article about the implantation of the Freestyle stentless bioprosthesis (Medtronic, Inc, Minneapolis, Minn) with respect to spacial orientation of patient coronary ostia. ¹ Arifi and his colleagues raise a number of important points that I would like to address without repeating some of my other published comments. ^2,3

First, I wonder how the authors estimated the prevalence of mild aortic insufficiency after subcoronary implantation of the Freestyle valve in our series at 25%, the prevalence being 18% at discharge, 16% at 6 months, and 8% at 1 year. Although statistical analysis of these data was judged inappropriate because of the small number of patients having residual postoperative aortic insufficiency, there was a clear decrease in this prevalence over the follow-up period that could not simply be explained by the insertion of a prosthesis according to the largest sizer that would pass through the anulus. I agree that oversizing the prosthesis can increase the coaptation surface between leaflets. However, on the other hand, how does one deal with the formation of crimps at both the inflow and outflow insertion levels and the presence of excessive porcine tissue that must be adjusted at the outflow insertion level?

Moreover, Arifi and his colleagues emphasize the importance of the sinuses of Valsalva, mandatory for competent valve closure, and that of the interleaflet triangles for proper valve function. However, I am not certain that the altered geometry of the native aortic root generated by the aortic valve pathology, usually manifested by dilatation of the sinuses of Valsalva and that of the sinotubular junction, could reproduce the same function as in a normal aortic root. We know that the formation and direction of the vertices are very different in this condition. I think our technique solves this problem, because it reestablishes a more physiologic anatomy to the altered native aortic geometry by preserving that of the porcine aortic root with the adjustment of the inflow and outflow insertion lines according to the patient's coronary ostia and by the trimming of left and right porcine sinuses to a degree just needed to keep the outflow suture line far enough from the coronary ostia. The native interleaflet triangles are included in the inflow suture by keeping the interrupted sutures in a horizontal line, except at the level of the membranous septum, where they are passed through the anulus to avoid any injury to the conduction system. I also believe that the space between the prosthesis and the native subcoronary sinus is better obliterated than any other subcoronary implantation technique, because of the proper adjustment of inflow and outflow insertion levels.

In the article referenced by Arifi and associates, ⁴ the tissue glue responsible for some complications is gelatin-resorcin-formol (GRF) glue and not fibrin glue, which was used in our series. Moreover, GRF glue was used mainly in the surgical treatment of aortic dissection and not in aortic valve replacement with stentless bioprostheses. As I previously stated, filling the space between the recipient and porcine noncoronary sinuses with fibrin glue allows the recipient's usually dilated noncoronary sinus to take on the geometry of the porcine sinus by homogeneously eliminating the dead space between them, this homogeneity not being obtained by applying interrupted sutures, as I had previously attempted before using fibrin glue. I have never had any problems related to the use of fibrin glue, in more than 150 cases of stentless valves and aortic homografts implanted by means of the same technique.

12/8/113010

doi:10.1067/mtc.2001.113010

References

1. Kalangos A, Trigo-Trindade P, Vala D, Panos A, Faidutti B. Aortic valve replacement with the Freestyle bioprosthesis with respect to spacial orientation of patient coronary ostia. J Thorac Cardiovasc Surg 2000;119:1185-93.[Abstract/Free Full Text]
   
2. Kalangos A. How to avoid problems with Freestyle valve implantation. Ann Thorac Surg 2000;70:1005.[Free Full Text]
   
3. Kalangos A. Stentless bioprostheses should be properly adjusted according to the disposition of patient coronary ostia at both the inflow and outflow insertion levels [letter]. J Thorac Cardiovasc Surg. In Press.
   
4. 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 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): Afksendiyos Kalangos Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kalangos, A. Search for Related Content PubMed Articles by Kalangos, A. Related Collections Valve disease