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J Thorac Cardiovasc Surg 2007;134:1094-1095
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Selective replacement of the noncoronary sinus of Valsalva: Preserving the sinus geometry to spare the bicuspid aortic valve

Operative Unit of Cardiac Surgery, "G. Pasquinucci" Hospital, The Institute of Clinical Physiology, The National Research Council, Massa, Italy

To the Editor:

We have read with extreme interest the paper by Gerosa and coworkers¹ published in a recent issue, describing the authors’ technique for selective replacement of the noncoronary sinus of Valsalva. Indeed, we adopted a similar approach in patients with bicuspid aortic valve and aneurysmal dilatation of the ascending aorta and aortic root since March 2003. In particular, when at surgical inspection the root dilatation appears to be confined to the noncoronary sinus, we replace it along with the ascending aorta in a way similar to that described by Gerosa and associates,¹ avoiding mobilization of the coronary sinus.

The only substantive difference between the Gerosa approach and ours consists in the fact that we replace the sinus with an isolated Dacron patch tailored on the removed aortic sinus, with the Dacron fabric corrugation oriented longitudinally (Figure 1). This allows us to obtain a self-expanding neosinus, similar to the neosinuses that can be obtained with the "Valsalva" graft,² and to remodel the sinotubular junction. The potential advantages of the re-creation of the sinuses and of the sinotubular junction have been previously shown both in finite element studies³ and in vivo at echocardiography.⁴ They consist in the achievement of a smoother valve closure with a reduced stress on the valve leaflets, which is supposed to help to preserve the long-term valve function.

View larger version (126K): [in this window] [in a new window]   Figure 1. A, The noncoronary sinus has been replaced with an appropriate-sized, bullet-shaped Dacron patch, with longitudinally oriented corrugation. B, A gentle traction on the aorta and on the right atrial appendage helps to expose the neo-noncoronary sinus, the "bombé" shape of which is clearly evident.

From March 2003 until now, 10 patients with dilatation of the noncoronary sinus and of the ascending aorta, and with a competent, well-functioning, bicuspid aortic valve, have undergone selective replacement of the noncoronary sinus at our institution. The in-hospital and short-term (up to 4 years) results have been excellent; all patients are alive and well, there has been no reoperation, and only 1 patient has residual aortic regurgitation that has been graded as mild at repeated echocardiographic examinations.

In conclusion, we share the conviction of Gerosa and colleagues that selective replacement of the dilated noncoronary sinus in association with replacement of the ascending aorta may be an excellent surgical option in patients with a well-functioning bicuspid aortic valve. We believe that the re-creation of sinuses and the remodeling of the sinotubular junction, by reducing the leaflet stress, may help to improve the long-term results of this approach.

References

1. Gerosa G, Pontarollo S, Liceto S, Di Marco F. An alternative technique for aortic root remodeling in patients with bicuspid aortic valve. J Thorac Cardiovasc Surg 2007;133:249-250.[Free Full Text]
   
2. De Paulis R, De Matteis GM, Nardi P, Scaffa R, Colella DF, Chiariello L. A new aortic Dacron conduit for surgical treatment of aortic root pathology. Ital Heart J 2000;1:457-463.[Medline]
   
3. Grande-Allen KJ, Cochran RP, Reinhall PG, Kunzelmann KS. Recreation of sinuses is important for sparing the aortic valve: a finite element study. J Thorac Cardiovasc Surg 2000;119:753-763.[Abstract/Free Full Text]
   
4. De Paulis R, De Matteis GM, Nardi P, Scaffa R, Bassano C, Chiariello L. Analysis of valve motion after the reimplantation type of valve-sparing procedure (David I) with a new aortic root conduit. Ann Thorac Surg 2002;74:53-57.[Abstract/Free Full Text]
   

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				R. De Paulis Aortic root surgery: from valve sparing to 'spare and plasty' Eur J Cardiothorac Surg, November 1, 2010; 38(5): 513 - 514. [Full Text] [PDF]

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): Alfredo Giuseppe Cerillo Pier Andrea Farneti Mattia Glauber Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cerillo, A. G. Articles by Glauber, M. Search for Related Content PubMed Articles by Cerillo, A. G. Articles by Glauber, M. Related Collections Valve disease Related Article