Florida Sleeve Research Articles

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.

Aortic Root Remodeling and Valve Sparing “New-Old” Technique

Objectives: Different surgical approaches have been suggested for aortic root aneurysm repair. We have developed our technique of aortic root remodeling, based on the plication of the wall of the sinuses of Valsalva and sinotubular junction, and covering the aortic root with tree patches in bovine pericardium. Methods Operative procedure: Aorta is resected above the sinotubular junction. The sinuses of Valsalva and the sinotubular junction are plicated. Three patches in bovine pericardium (one for each sinus) are used to cover the aortic root. The patches are fixed to the annulus by three sub annular stitches placed under the nadir of the commissures. The distal end of these patches are fixed at the level of sinotubular junction between one another and commissural aortic wall. Results: From January 2000 to February 2011 130 patients underwent this operation. There were two hospital deaths. Aortic valve insufficiency was not significant in all but four patients for severe aortic insufficiency required aortic valve replacement during the procedure. In the follow up no significant enlargement of the aortic root was detected. Three patients were reoperated for aortic valve replacement. Conclusion: With our technique, we remodel the sinuses of Valsalva and sinotubular junction to achieve the normal functioning of the aortic valve, by fixing the aortic annulus and covering the aortic root with three patches of bovine pericardium. We have found advantages in our new method compared with valve sparing and Florida Sleeve procedures.

Valve-Sparing Repair of Aortic Root Aneurysms: An Update on the Florida Sleeve

Aortic valve-sparing reimplantation remains an effective technique for repair of aortic root aneurysms. Studies indicate that the Florida Sleeve procedure is dimensionally stable and durable in the early postoperative period; however, our technique has evolved. We describe a 10-year institutional experience and the technical update of the Florida Sleeve repair for root aneurysms.

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.

Florida Sleeve Repair for Aortic Root Aneurysm

A 74-year-old man was diagnosed with aortic root aneurysm and two-vessel coronary disease. Echocardiographic assessment revealed an enlarged sinus of Valsalva 60 mm in diameter with mild aortic regurgitation. Florida sleeve repair was performed using a vascular graft combined with coronary artery bypass grafting. The postoperative course was uncomplicated and follow-up echocardiographic evaluations showed an aortic root diameter of 38 mm without aortic insufficiency up to 1 year after surgery.

Reverse Graft Placement in the Florida Sleeve Procedure for Aortic Root Aneurysm

Since August 2009, 22 patients with aortic root aneurysm have been successfully operated on with our new aortic remodeling technique as follows: after placement of the Gelweave (Vascutek, Ltd., Inchinnan, UK) Valsalva vascular graft in the reverse manner to the Florida sleeve procedure, the aortic annulus was fixed with the collar of this prosthesis at the level of the basal ring and the aortic root was wrapped with the prosthesis. Furthermore, the aortic valve commissures were resuspended. The distal end of the graft and the transected aortic wall were sutured together with running sutures when they were anastomosed to the stump of the distal ascending aorta.

Valve-Sparing Aortic Root Replacement in Loeys-Dietz Syndrome

Loeys-Dietz syndrome (LDS) is a recently recognized aggressive aortic disorder characterized by root aneurysm, arterial tortuosity, hypertelorism, and bifid uvula or cleft palate. The results of prophylactic root replacement using valve-sparing procedures (valve-sparing root replacement [VSRR]) in patients with LDS is not known. We reviewed all patients with clinical and genetic (transforming growth factor-β receptor mutations) evidence of LDS who underwent VSRR at our institution. Echocardiographic and clinical data were obtained from hospital and follow-up clinic records. From 2002 to 2009, 31 patients with a firm diagnosis of LDS underwent VSRR for aortic root aneurysm. Mean age was 15 years, and 24 (77%) were children. One (3%) patient had a bicuspid aortic valve. Preoperative sinus diameter was 3.9±0.8 cm (z score 7.0±2.9) and 2 (6%) had greater than 2+ aortic insufficiency. Thirty patients (97%) underwent reimplantation procedures using a Valsalva graft. There were no operative deaths. Mean follow-up was 3.6 years (range, 0 to 7 years). One patient required late repair of a pseudoaneurysm at the distal aortic anastomosis, and 1 had a conversion to a David reimplantation procedure after a Florida sleeve operation. No patient suffered thromboembolism or endocarditis, and 1 (3%) patient experienced greater than 2+ late aortic insufficiency. No patient required late aortic valve repair or replacement. Loeys-Dietz syndrome is an aggressive aortic aneurysm syndrome that can be addressed by prophylactic aortic root replacement with low operative risk. Valve-sparing procedures have encouraging early and midterm results, similar to those in Marfan syndrome, and are an attractive option for young patients.

Valve-sparing and valve-replacing techniques for aortic root replacement in patients with Marfan syndrome: Analysis of early outcome

A prospective, international registry study was initiated to provide contemporary comparative data on short-term clinical outcomes after aortic valve-sparing and aortic valve-replacing root operations in patients with Marfan syndrome. The purpose of this initial report is to describe the study design and to compare early outcomes in the first 151 enrolled patients. We assessed 30-day outcomes in 151 patients who met strict Ghent diagnostic criteria for Marfan syndrome and underwent aortic root replacement with either valve-replacing (n = 46) or valve-sparing techniques (n = 105) at one of 18 participating centers. In the valve replacement group, a mechanical composite valve graft was used in 39 (85%) patients and a bioprosthetic valve in 7 (15%). In the valve-sparing group, David V procedures were performed in 57 (54%) patients, David I in 38 (36%), David IV in 8 (8%), Florida sleeve in 1 (1%), and Yacoub remodeling in 1 (1%). No in-hospital or 30-day deaths occurred. Despite longer crossclamp and cardiopulmonary bypass times in the valve-sparing group, there were no significant between-group differences in postoperative complications. Thirty-day valve-related complications occurred in 2 (4%) patients undergoing valve replacement and in 3 (3%) undergoing valve-sparing procedures (P = .6). The analysis of early outcomes revealed that valve-sparing techniques were the most common approach to root replacement in patients with Marfan syndrome in these centers. The complexity of valve-sparing root replacement did not translate into any demonstrable adverse early outcomes. Subsequent analysis will compare the 3-year durability of these two surgical approaches.

Early Outcomes Using the Florida Sleeve Repair for Correction of Aortic Insufficiency due to Root Aneurysms

The Florida sleeve procedure is a simplified valve-sparing technique for repair of functional type I aortic insufficiency associated with root aneurysms. Midterm outcomes are reported, including standard echocardiographic measurements. The study included all patients undergoing the Florida sleeve procedure who had at least 2 years of postoperative echocardiographic follow-up. Data were acquired preoperatively and postoperatively at 1 week and 1, 2, and 3 years. Measurements analyzed included left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), and degree of aortic insufficiency. Complete echocardiographic data for a mean 32 +/- 6.3 months after repair were available for 18 patients. Mean LVEDD decreased from 51.6 +/- 7.4 to 49.7 +/- 6.3 mm at 1 week (p = 0.05) and 47.1 +/- 6.3 mm at 1 year (p = 0.008), and remained unchanged at 47.2 +/- 6.6 and 47.1 +/- 5.0 mm at 2 and 3 years. Mean LVESD decreased from 35.2 +/- 7.6 to 32.9 +/- 7.0 mm at 1 week (p = 0.002) and 30.7 +/- 5.6 mm at 1 year (p < 0.001), and remained unchanged at 30.9 +/- 6.2 and 31.7 +/- 4.9 mm after 2 and 3 years. The mean grade of aortic insufficiency decreased from 2.61 +/- 0.78 to 1.39 +/- 0.85 mm at 1 week (p < 0.001) and remained 1.39 +/- 0.84 mm at 1 year. Aortic insufficiency increased to 1.72 +/- 0.89 (p = 0.03) at 2 years and decreased to 1.67 +/- 0.50 (p = 0.59, from 1 week postoperatively) at 3 years. The sustained reduction of left ventricular dimensions 3 years after operation suggests the Florida sleeve procedure is a durable valve repair. A minor increase in the degree of aortic insufficiency warrants close follow-up, but the absence of an increase of LVEDD supports continued use of the procedure in closely studied series.

Valve-sparing and valve-replacing techniques for aortic root replacement in patients with Marfan syndrome: Analysis of early outcome

A prospective, international registry study was initiated to provide contemporary comparative data on short-term clinical outcomes after aortic valve-sparing and aortic valve-replacing root operations in patients with Marfan syndrome. The purpose of this initial report is to describe the study design and to compare early outcomes in the first 151 enrolled patients. We assessed 30-day outcomes in 151 patients who met strict Ghent diagnostic criteria for Marfan syndrome and underwent aortic root replacement with either valve-replacing (n = 46) or valve-sparing techniques (n = 105) at one of 18 participating centers. In the valve replacement group, a mechanical composite valve graft was used in 39 (85%) patients and a bioprosthetic valve in 7 (15%). In the valve-sparing group, David V procedures were performed in 57 (54%) patients, David I in 38 (36%), David IV in 8 (8%), Florida sleeve in 1 (1%), and Yacoub remodeling in 1 (1%). No in-hospital or 30-day deaths occurred. Despite longer crossclamp and cardiopulmonary bypass times in the valve-sparing group, there were no significant between-group differences in postoperative complications. Thirty-day valve-related complications occurred in 2 (4%) patients undergoing valve replacement and in 3 (3%) undergoing valve-sparing procedures (P = .6). The analysis of early outcomes revealed that valve-sparing techniques were the most common approach to root replacement in patients with Marfan syndrome in these centers. The complexity of valve-sparing root replacement did not translate into any demonstrable adverse early outcomes. Subsequent analysis will compare the 3-year durability of these two surgical approaches.

A Comparison of Polysomnography and the SleepStrip in the Diagnosis of OSA

The Florida sleeve (FS) procedure was developed as a simplified approach for repair of functional type I aortic insufficiency secondary to aortic root aneurysm. We evaluated postoperative aortic valve function, long-term survival, and freedom from reoperation in Marfan syndrome patients who underwent the FS procedure at our center.All Marfan syndrome patients undergoing FS procedure from May 2002 to December 2014 were included. Echocardiography assessment included left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), ejection fraction, and degree of aortic insufficiency (none = 0, minimal = 1, mild = 2, moderate = 3, severe = 4). Social Security Death Index and primary care physicians’ report were used for long-term follow-up.Thirty-seven Marfan syndrome patients, 21 (56.8%) men and 16 (43%) women with mean age of 35.08 ± 13.45 years underwent FL repair at our center. There was no in-hospital or 30-day death or stroke. Two patients required reoperation due to bleeding. Patients’ survival rate was 94% at 1 to 8 years. Freedom from reoperation was 100% at 8 years. Twenty-five patients had postoperative follow-up echocardiography at 1 week. Aortic insufficiency grade significantly decreased after the procedure (preoperative mean ± SD: 1.76 ± 1.2 versus 1-week postoperative mean ± SD: 0.48 ± 0.71, p < 0.001), and mean LVEDD decreased from 52.23 ± 5.29 mm to 47.53 ± 8.89 mm (p = 0.086). Changes in LVESD (35.33 ± 9.97 mm to 36.58 ± 9.82 mm, p = 0.58) and ejection fraction (57.65% ± 6.22% to 55% ± 10.83%, p = 0.31) were not significant.The FS procedure can be performed safely in Marfan syndrome patients with immediate improvement in aortic valve function. Long-term survival and freedom from reoperation rates are encouraging.

The Florida Sleeve: A New Technique for Aortic Root Remodeling With Preservation of the Aortic Valve and Sinuses

Aortic valve salvage remains the procedure of choice for patients with incompetent valves and normal leaflet morphology. Here my colleagues and I describe a new technique for aortic root remodeling with preservation of the aortic valve.