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J Thorac Cardiovasc Surg 2007;134:1095
© 2007 The American Association for Thoracic Surgery
Letter to the Editor |
a Division of Cardiac Surgery, Department of Cardiological, Thoracic and Vascular Sciences, Padua University Medical School, Padua, Italy
b Division of Cardiology, Department of Cardiological, Thoracic and Vascular Sciences, Padua University Medical School, Padua, Italy
We read with interest the letter by Cerillo, Farneti, and Glauber, who propose a technique resembling our approach1
for reconstruction of the ascending aorta in patients with normofunctioning bicuspid aortic valve (BAV).
The choice by Cerillo and colleagues to reconstruct the aortic root and the noncoronary sinus with a hand-crafted Valsalva sinus graft composed of two separate segments of a Dacron prosthesis, perpendicularly oriented so as to mimic the conformation of the Gelweave Valsalva graft (Sulzer Vascutek, Renfrewshire, Scotland), is a smart idea, nevertheless recalling the custom-made Valsalva graft previously proposed by Robicsek and Thubrikar.2
The aim is to replace the native dilated noncoronary sinus with a self-expanding neosinus, favoring a more physiologic leaflet closure with reduced stress, ultimately resulting in long-lasting preservation of native valve function.
The technique suggested by Cerillo and colleagues requires an additional suture between the two Dacron segments (graft-to-graft suture), which, in their experience, was not associated with hemorrhagic complications. However, the complexity of surgery is undoubtedly increased and the potential advantage of recreating an expandable neosinus in the presence of a BAV, which intrinsically has an impaired hydrodynamic performance, has not been demonstrated yet. It is reasonable to hypothesize that the physiologic characteristics of the aortic root differ in the presence of a bicuspid compared with those in the presence of a tricuspid valve. In his theory for aortic valve closure, Bellhouse3 evidenced the paramount importance of the role of the sinuses, but also underlined that, in presence of a stenotic valve, the turbulent jet generated by the blood flow deceleration in end-systole is not captured by the sinuses, and no blood vortices can be evidenced in the sinuses either. More recently, Robicsek and colleagues4 investigated specifically the blood flow pattern through the BAV by a computer-assisted digitalized model, evidencing asymmetric and stenotic abnormalities even in normally functioning valves. These abnormalities are likely to create recirculation vortices, which cannot be confined into the sinuses, like in the trileaflet valve, but extend into the ascending aorta.
Nevertheless, the data reported by Cerillo, Farneti, and Glauber strengthen the favorable results of our experience, reinforcing our conviction about the opportunity to selectively replace the ascending aorta and noncoronary sinus in patients with BAV.
References
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