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J Thorac Cardiovasc Surg 2007;134:823-824
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

The sinuses of Valsalva: They should be anatomically correct and physiologically compliant

Francis Robicsek, MD, PhD

The Carolinas Heart Institute, Carolinas Medical Center, Charlotte, NC

To the Editor:

The article "Six Stitches to Create a Neosinus in David-type Aortic Root Resuspension" by Moritz and colleagues, which appeared in the February issue of the Journal,1Go confirms our observations made in the late 1980s on handmade "Valsalva" grafts2Go and that the onion shape itself guarantees neither physiologic function nor longevity of aortic valve leaflets. Digitized stress measurements further demonstrated that even if 3 sinuses are refabricated, as the authors propose, significant stress reduction was obtained only if the neosinuses closely matched the anatomy of the preserved or implanted leaflets.3Go One may get closest to such an arrangement with "custom-made" oyster-form concave leaflets, handmade to match the anatomic features4Go (Figure 1).


Figure 1
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  		Figure 1. The Robicsek–Thubrikar "tailor-made" sinus graft.

 
However, even if someone may be able to accomplish an anatomic match between sinuses and leaflets, normal compliance of the aortic wall, a prerequisite to significant stress reduction, will remain elusive. Our experience indicates that positioning the "grooves" of the Dacron prosthesis at the level of the neosinuses vertically will indeed provide some compliance, but it will not reach that of a normal aortic root. Also, with the passage of time even this disappears. It is indeed important to try to imitate Mother Nature in our efforts to restore and maintain aortic valve function by creating neosinuses. We agree with the authors that the onion configuration itself provides very little stress reduction and that the presence of 3 neosinuses may reduce the stress on the aortic leaflets; however, it also needs to be emphasized that this will occur only if the sinuses are appropriately matched with the leaflets, and unless long-lasting compliance is provided, the stress reduction will be temporary and miniscule.

References

  1. Mortiz A, Risteski P, Dogan S, Macit H, Akbulut B, Zierer A, et al. Six stitches to create a neosinus in David-type aortic root resuspension. J Thorac Cardiovasc Surg 2007;133:560-562.[Free Full Text]
  2. Robicsek F. A new ascending aortic prosthesis. 1992United States Patent Office, No. 5, 139, 511, Aug. 18.
  3. Zehr KJ, Thubrikar MJ, Gong CG, Headrick JR, Robicsek F. Clinical introduction of a novel prostheses for valve preserving aortic root reconstruction for annuloaortic ectasia. J Thorac Cardiovasc Surg 2000;120:692-698.[Abstract/Free Full Text]
  4. Thubrikar MJ, Robicsek F, Gong GG, Fowler BL. A new aortic root prosthesis with compliant sinuses for valve-sparing operations. Ann Thorac Surg 2001;71:S318-S322.[Abstract/Free Full Text]

Related Article

Reply to the Editor
Anton Moritz and Tayfun Aybek
J. Thorac. Cardiovasc. Surg. 2007 134: 824. [Extract] [Full Text] [PDF]




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