Florida Sleeve Technique Research Articles

Long-term result of aortic root remodeling using the Florida sleeve technique in a patient with connective tissue dysplasia and aortic root aneurysm without aortic insufficiency

Aortic root remodeling using the Florida sleeve technique was proposed as a simpler alternative to classical reconstructive interventions in patients with aortic root aneurysm without aortic insufficiency. We present a 10-year result of valve-sparing surgical treatment using the Florida sleeve technique in a patient with connective tissue dysplasia and aortic root aneurysm.

Reply to de Kerchove et al.: 'Rather addition than extension of Florida sleeve indications'.

We read the invited commentary by de Kerchove et al. entitled ‘Is extension of Florida Sleeve indications taking us in the right direction?’ [1] in reference to our work [2] with great interest. We thank the authors for their valuable comments. In fact, there is no uniform technique to perform aortic valve (AV) reimplantation. David [3] himself published variations up to David V. There is a vast body of technical development. In our department, we also implemented steps to create a sinus bulge to avoid retraction of the right coronary base and to adapt for the geometry of bicuspid AVs [4]. We have started using AV reimplantation in 1992 and over years only sporadically used the Florida sleeve technique. Performing more complex operations and treating elderly patients, we had a concern of prolonged clamp times especially when concomitant surgery was indicated. Another indication was borderline dilatation of the aortic root. The question is what to do with a young adult with myxomatous mitral valve disease and an aortic root of 40 mm diameter? This kind of wrapping of the root, nearly without any risk of bleeding, could be an acceptable prophylactic tool. In AV repair, one faces frequently dilated roots by far not reaching the current indication for the root replacement. The sleeve around the aorta provides potentially a stable geometry and eases the judgement for AV cusp repair.

Early and medium-term results of the Florida Sleeve technique for aortic root ectasia

Early and medium-term results of the Florida Sleeve technique for aortic root ectasia

Aortic root reinforcement using the Florida sleeve technique in a patient with acute aortic dissection type A

Stanford type A acute aortic dissection is an inherently lethal condition that is regarded as a surgical emergency. The Bentall procedure is considered the gold standard for patients requiring aortic root replacement. However, this method can be technically difficult for less-experienced surgeons. Complications encountered after composite graft replacement include distortion of the proximal part of the coronary artery, bleeding from the conduit implant site, and reattached coronary artery origins caused in general by a consumption coagulopathy. In cases for which aortic valve preservation is not applicable and the root is not dissected or dilated, surgeons often opt for less complicated techniques like aortic valve and supracoronary ascending aortic replacement. Nevertheless, these patients carry a high risk of late aortic root dilatation and subsequent reoperation. The goal of aortic root reinforcement by the Florida sleeve technique is to encase the aortic root to prevent any further dilatation and perioperative bleeding.

Florida Sleeve for type A dissection

: In properly selected patients, an aortic root repair with valve salvage is a viable alternative to root replacement. Acute type A aortic dissections are often emergency operations with a high complexity. These cases are particularly difficult when the aortic root is enlarged, but the aortic valve leaflets and morphology are normal. In the setting of an acute ascending aortic dissection and enlarged aortic root, preservation of the valve via the use of the Florida Sleeve root repair technique is an alternative to root replacement. We present a case of our standard Florida Sleeve root repair in a patient with an ascending aortic aneurysm of 6.0 cm and an aortic root of 5.3 cm with moderate aortic insufficiency. The patient is a healthy 57-year-old male that had normal trileaflet anatomy but central aortic insufficiency appearing to be related to his root dilation on pre-operative echocardiogram. The Florida Sleeve technique for root remodeling with preservation of the aortic valve and sinuses is a technique for saving the aortic valve while narrowing the annulus and sinotubular junction. Familiarity with root replacement and valve preserving techniques during non-emergency setting is crucial in order to complete the procedure in an efficient manor during an aortic dissection operation.

Operation in DeBakey type I acute aortic dissection according to the Florida Sleeve technique

Despite the fact that recent decades have witnessed significant advances in treatment of patients with DeBakey type I acute aortic dissection, it still remains difficult to restore the aortic root when the dissection extends to the Valsalva's sinuses. Thinned aortic walls are vulnerable to traumatization on applying a vascular suture. We used in patients with this pathology the Florida sleeve technique in order to reinforce the weakened aortic root. After mobilization of the aortic root and coronary arteries, the transplant 'wraps' the sinuses from the outside, like the neoadventitia, in order to strengthen the weakened aortic wall. The graft's diameter should be selected with due regard for tight enwrapment of coronary sinuses in their maximal dilatation and, if necessary, preserving the possibility of narrowing the fibrous ring. This technique is simple and effective. First, it allows strengthening the weakened root, secondly helping to prevent haemorrhage. Besides, it may prove alternative, should preservation or correction of the geometry of the aortic root be required.

Leaflet kinematics after the Yacoub and Florida-sleeve operations: results of an in vitro study.

The Florida-sleeve is a valve-sparing technique that causes minimal interference to leaflet kinematics and aortic root dynamism. The aim of this in vitro study was to evaluate the effects of the Florida-sleeve and Yacoub techniques on aortic leaflet kinematics. Two groups of 6 whole porcine hearts were treated with either the Florida-sleeve technique or the Yacoub technique and tested in a pulsatile loop. Valve fluid dynamics, coronary flow analysis and valve echocardiograms were performed both before and after the procedures. Both procedures showed no difference in rapid valve opening time as compared with their respective baseline values. The Florida-sleeve procedure showed a shorter slow closing time (192 ± 19 ms vs baseline 244 ± 14 ms, P = 0.016) and increased slow closing velocity (-1.5 ± 0.4 cm/s vs baseline -0.8 ± 0.4 cm/s, P = 0.038). In the rapid valve closing phase, the Yacoub procedure showed a trend towards slower closing valve velocity (-16 ± 9 cm/s vs baseline -25 ± 9 cm/s, P = 0.07). The Yacoub procedure showed larger leaflet displacement at the end of the slow valve closing time that was 2.0 ± 0.5 cm vs baseline 1.5 ± 0.3 cm, P = 0.044. When comparing the Florida-sleeve and Yacoub procedures, the former showed statistically significant shorter slow valve closing time (P = 0.017). This study showed that the Florida-sleeve technique alters the slow closing phase of the aortic valve leaflet kinematics when compared with both the normal baseline and Yacoub procedure, while the latter showed a larger leaflet displacement before the rapid closing valve phase.

Unusual, Radical Treatment of Type A Aortic Dissection: A Case Report.

Type A aortic dissection, according to Stanford classification, is a surgical emergency with high morbidity and carries 56% of in-hospital mortality when surgical intervention is not performed. The surgical mortality at 30 days is 10 to 20%. The therapeutic goals are to replace the diseased ascending aorta and to treat or to monitor the distal aortic patent false lumen. When the dissection involves the aortic root and the architecture of aortic valve is normal, the surgical techniques used could be multiple: reinforce the aortic root and spare the native aortic valve or replace the aortic valve and the aortic root. The Florida sleeve technique has been developed to treat the aortic aneurysm, sparing the aortic valve in patients with connective tissue disease. Some case reports have described the use of this technique to treat an acute aortic dissection. In the following case, we present a single stage repair of the ascending aorta, aortic arch, and proximal intrathoracic aorta in a patient with Type A aortic dissection through the contemporaneous use of two techniques: Florida sleeve and Vascutek “Thoraflex” hybrid prosthesis. The use of these two techniques allows the repair/replacement of the proximal intrathoracic aorta, the sparing of the native aortic valve, the employment of a hybrid prosthesis to replace the supraortic vessels, and the creation of a descending aortic landing zone for later, distal intervention.

Remote results of Florida Sleeve technique in patients with ascending aortic aneurysms and aortic insufficiency.

The aim of our investigation was to assess the remote results of valve-sparing aortic root reimplantation into the graft (Florida Sleeve technique) compared with reimplantation of the aortic valve into the graft (David technique) during surgical correction of ascending aortic aneurysms accompanied by concomitant aortic insufficiency. Our single-centre, blind, prospective, randomized study carried out from 2011 to 2015 included a total of 64 patients with ascending aortic aneurysms and aortic insufficiency. The patients were randomized into 2 groups: group I - aortic root reimplantation according to the Florida Sleeve technique (FS group) and group II - reimplantation of the aortic valve according to the T. David technique in David I modification (D group). The groups did not statistically differ by the baseline clinical profile. The overall 7-year survival for the FS group and D group amounted to 83% and 85.6%, respectively (p=0.98). Assessing the competing risks of mortality related to cardiovascular or other causes revealed no differences. Freedom from prosthetic repair of the aortic valve in the remote follow-up period amounted to 92.8% and 85.8% for the FS group and D group, respectively (p=0.4). According to the obtained findings, the technique of a valve-sparing operation is not a predictor of either lethality (RR 0.98 (95% CI 0.23-4.15), p=0.98) or prosthetic repair of the aortic valve (RR 2.03 (95% CI 0.40-14.63), p=0.40) in the remote period of follow up. Aortic root reimplantation inside the prosthesis according to the Florida Sleeve technique makes it possible to simplify and accelerate the procedure of aortic root reconstruction in patients with aortic root aneurysms and concomitant aortic insufficiency, demonstrating long-term results comparable with those of the David technique.

Florida sleeve technique for a right sinus of Valsalva aneurysm: a case report

BackgroundFlorida sleeve technique was reported by Hess et al. as a new technique of valve sparing aortic root replacement without the requirement of entire aortic root wall resection and coronary artery reconstruction. We present a rare case of an unruptured aneurysm of the right sinus of Valsalva that was successfully treated with resection of the aneurysm and the Florida sleeve technique.Case presentationA 72-year-old man was admitted for the treatment of an unruptured aneurysm of the right sinus of Valsalva. Computed tomography showed an aneurysm of the right sinus of Valsalva measuring > 40 mm and protruding into the right ventricular outflow tract. The aneurysm dilated up to 5 mm per year, and the left sinus of Valsalva and non-coronary sinus of Valsalva also showed dilation, and he underwent resection of only the right sinus of Valsalva aneurysm and valve sparing aortic root replacement with the Florida sleeve technique.ConclusionsWe performed valve-sparing aortic root replacement with the Florida sleeve technique. It could reduce surgical risks and prevent a dilatation of the residual sinus of Valsalva through coverage with a graft for a long term.

Aortic cusp extension valvuloplasty: repair with an extracellular patch.

IntroductionThe proportion of valve repair procedures is increasing in experienced centers. The aim of the study was to assess the clinical and echocardiographic outcomes after aortic valve reconstruction with a novel surgical technique.Material and methodsThe study group consisted of 30 patients (23 male and 7 female) at a mean age of 35 ± 14 years. In patients with aortic root aneurysm the reimplantation or Florida sleeve technique was used. A sub-commissural annuloplasty, plication of the free edge of the cusp, shaving, and commissurotomy were performed. At this stage of surgery aortic repair was then attempted by cusp extension. Since 2013 the strips have been tailored from extracellular matrix.ResultsThe mean aortic cross-clamp time was 90 ± 32 min. The mean cardiopulmonary bypass time was 126 ± 38 min. There was no in-hospital death. Re-exploration for bleeding was required in 1 patient. During follow-up, 1 patient needed reoperation at 1 year due to endocarditis. All patients remained alive in New York Heart Association (NYHA) functional class I. The echocardiographic findings remained unchanged in all cases during follow-up.ConclusionsOur modification of aortic valve repair results in a good outcome.

Valve-Sparing Aortic Root Replacement: Early and Midterm Outcomes in 83 Patients

Valve-sparing aortic root replacement (VSARR) is an alternative to traditional composite valve graft (CVG) root replacement. We examined early and midterm outcomes after VSARR. A combined retrospective/prospective study was performed in 83 patients who underwent VSARR (16%) among 515 patients who underwent aortic root replacement during a nearly 12-year period. Thirty-six patients (43%) had a connective tissue disorder, 3 patients (4%) had acute aortic dissection, and 40 (48%) patients had at least moderate aortic regurgitation (AR). Twenty-eight patients (34%) had left ventricular hypertrophy or dilatation. The reimplantation VSARR technique was used in 82 patients (99%), and the Florida sleeve technique was used in 1 patient. Thirty-two patients (39%) underwent concomitant aortic arch replacement. For early survivors, the median duration of follow-up was 3.5 years (range, 5 days-12.2 years). One patient had severe AR after VSARR that necessitated intraoperative conversion to a mechanical CVG. The 1 operative death and 1 stroke occurred in a patient with acute dissection. Actuarial survival was 96.4%±2.0% at 2 years and 86.9%±5.6% at 8 years. Six patients (7%) had late valve-related complications: 1 died of endocarditis, 4 underwent reoperation for severe AR and received replacement valves, and 1 had severe AR and is being monitored. Freedom from repair failure (reoperation, endocarditis, or severe AR) was 94.8%±2.6% at 2 years and 87.3%±5.7% at 8 years. Valve-sparing aortic root replacement can have excellent early and respectable midterm outcomes, even when combined with arch repair. Further follow-up remains necessary to evaluate the long-term durability of VSARR.

A modified root reinforcement technique for acute aortic dissection with a weakened aortic root: a modified Florida sleeve technique and two cases report

Despite marvelous advances in repair for acute type A aortic dissection over past decades, it remains challenging to repair the aortic root when aortic dissection extended to the sinuses causes the fragile root because of its thinner layers, which are susceptible to suture trauma. Here, we describe a modified Florida sleeve technique to strengthen the weakened aortic root. After mobilization of the aortic root and the coronary arteries, a designed Dacron tube graft was wrapped outside the sinuses as neo-adventitia to reinforce the dissected weakened wall. During surgery for aortic dissection, our technique is easy and effective to reinforce a weakened root and avoid bleeding. Furthermore, this might be an alternative technique to restore and maintain the geometry of the aortic root.