HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gino Gerosa Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Gerosa, G. Search for Related Content PubMed PubMed Citation Articles by Gerosa, G. Related Collections Valve disease Related Article

J Thorac Cardiovasc Surg 2006;131:759-760
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

Inappropriate surgical technique or prosthesis malfunctioning?

Cardiovascular Surgery Institute, Padua University Medical School, Via Giustiniani 2, 35100, Padova, Italy

To the Editors:

The Jude Medical (SJM) Regent valve (St Jude Medical, Inc, St Paul, Minn) represents the ultimate step in bileaflet valve engineering aiming to overcome prosthesis-patient mismatch. Compared with the SJM Hemodynamic Plus model, also the carbon rim is supra-annular. The new configuration offers a greater orifice area for a given annulus diameter. ¹

Øvrum and Tangen ² reported 3 cases of intraoperative rereplacement of the SJM Regent aortic valve. Several issues raised by the article are questionable and misleading, and careful attention must be paid before "re-engineering" daily practice according to erroneous concepts.

First, claiming an acute arrest is intrinsically imprecise, since "leaflet arrest" implies a sudden opening discontinuance in a previously correctly functioning valve. In this case, the alleged arrest was actually the absence of leaflet motility and housing rotation during intraoperative testing on the arrested heart. Subvalvular tissue was entrapped into the motion mechanism. Acute arrest is a threatening definition evocative of malfunction, rather than technical difficulties, possibly related to the modality of the implant. In fact, as authors claim, "after explantation there were no signs of mechanical dysfunction."

Second, the authors refer to a previous article ³ reporting 2 similar cases in which the SJM Standard valve was used. The only common element between the articles is inappropriate definition of the episode as leaflet arrest. In fact, in Grattan and Thulin's article, no tissue entrapment was evidenced intraoperatively: leaflet motionlessness was reproduced onto the explanted prosthesis, compressing the sewing cuff with a clamp and then, in vitro, by a push-rod device applying a variable axial force, suggesting an intraoperative oversizing.

Third, the authors report that in 2 cases the SJM Regent valve was replaced with a CarboMedics (CM) valve (Sulzer Carbomedics Inc, Austin, Tex) of similar size. This statement is incorrect because similar label size does not imply equal diameter, the size 27 CM valve being smaller than the size 27 Regent valve. This supports an oversizing due to inappropriate prosthesis selection as a causative factor. At our institution, we routinely proceed with valve sizing only after positioning the annular sutures to avoid an incorrect estimation of the sutures' intra-annular encumbrance.

We believe that the main issue of Ovrum and Tangen's experience is how subvalvular tissue could get entrapped in the valve's hinges. In the SJM Regent valve the pivot mechanism is placed below the annulus. ² Therefore, we usually adopt some shrewdnesses during the implant. After valve seating, we secure the suture cuff to the annulus by 3 tourniquets fastened onto the commissures. An additional tourniquet might be placed below the noncoronary sinus, representing an intraprocedural "blind window." Only after testing the correct opening of the valve, held by tourniquets in what will be its definitive position, do we tide the sutures. The tourniquets also guarantee that cuff's anchorage is uniformly perpendicular to the aortic wall, with no leaning; they avoid, during tiding, an inappropriate sliding of the intra-annular portion of the valve below the aortic annulus, resulting in a dangerous proximity to the subvalvular tissue.

Adopting this cautiousness, we did not encounter any need to rereplace a Regent valve or any other mechanical valve implanted in the aortic position.

	References

Top References

 

1. Bottio T, Caprili L, Casarotto D, Gerosa G. Small aortic annulus. the hydrodynamic performances of 5 commercially available bileaflet mechanical valves. J Thorac Cardiovasc Surg 2004;128:457-462.[Abstract/Free Full Text]
   
2. Øvrum E, Tangen G. Acute leaflet arrest in St Jude Medical Regent aortic valve. J Thorac Cardiovasc Surg 2005;129:1446.[Free Full Text]
   
3. Grattan MT, Thulin LI. Leaflet arrest in St Jude Medical and Carbomedics valves. an experimental study. Eur J Cardiothorac Surg 2004;25:953-957.[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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gino Gerosa Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Gerosa, G. Search for Related Content PubMed PubMed Citation Articles by Gerosa, G. Related Collections Valve disease Related Article