Valsalva Graft Research Articles

A novel, simplified protected Ross technique: The “Seattle shawl” procedure

ObjectiveAutograft dilation and subsequent aortic regurgitation remain a challenge in the long term after the Ross procedure in adults. We have developed a novel technique for a modified Dacron wrap of the pulmonary autograft to help stabilize and mitigate this issue. MethodsIn 2022, we formalized a patient-specific tailored algorithm for autograft protection during the Ross procedure, including use of a modified Dacron wrap (“Seattle shawl”). This technique involves the use of a Valsalva graft, which is “keyholed” to facilitate coronary button implantation on the autograft and then wrapped around the pulmonary autograft. A total of 6 patients have undergone the Seattle shawl procedure. Mean follow-up time was 11.8 months (range, 4-17 months). ResultsAll 6 patients had bicuspid aortic valves with severe aortic regurgitation. Mean aortic annulus size was 30.3 mm, and mean aortic root diameter was 4.4 cm. There were no perioperative strokes, reinterventions, or mortalities. All patients had mild or less aortic regurgitation on the most recent echocardiogram. Aortic root diameters were between 3.2 and 3.9 cm on the most recent imaging examination. There were no mortalities or complications observed during the follow-up period. ConclusionsPulmonary autograft dilation remains a challenge postoperatively after the Ross procedure in adults. Multiple interventions have been used to minimize this phenomenon. These include technical modifications such as annuloplasty rings or complete inclusion of the autograft within a Dacron graft. We present a novel, straightforward technique for autograft protection using a modified Valsalva graft. Early outcomes in 6 patients appear promising with this technique.

Completion Bentall procedure for a huge aortic root pseudoaneurysm after surgery for acute aortic dissection: A case report

A 56-year-old man with a history of emergency ascending aortic and aortic valve replacement for acute type A aortic dissection 6 months previously developed a huge pseudoaneurysm arising from the sinus of Valsalva due to recurrent aortic root dissection. The patient urgently underwent the completion Bentall procedure with coronary artery reconstruction using interposing grafts. During surgery, the non-coronary sinus of Valsalva was repeatedly dissected and ruptured, where surgical glue was applied in the previous operation. The 25-mm REGENT mechanical valve® from the previous operation was left in place, and 2-0 bladed mattress sutures were circumferentially placed in the sewing ring of the prosthesis. A 28-mm Valsalva graft® was cut at the middle of its skirt portion, through which these sutures were passed and tied, and was seated to completely cover the valve cuff. The completion Bentall procedure is considered a feasible technique for reoperative aortic root replacement in patients with a prosthetic aortic valve following acute type A aortic dissection repair. It is important to accurately measure the outer diameter of the prosthetic valve to ensure proper fit of the graft and to minimize the risk of bleeding.

High-speed videography of an exemplary porcine aortic valve after the valve-sparing aortic root replacement using the Valsalva graft configuration.

High-speed videography of an exemplary porcine aortic valve after the valve-sparing aortic root replacement using the Valsalva graft configuration.

Biomechanics and clinical outcomes of various conduit configurations in valve sparing aortic root replacement.

Several conduit configurations, such as straight graft (SG), Valsalva graft (VG), anticommissural plication (ACP), and the Stanford modification (SMOD) technique, have been described for the valve-sparing aortic root replacement (VSARR) procedure. Prior ex vivo studies have evaluated the impact of conduit configurations on root biomechanics, but the mock coronary artery circuits used could not replicate the physical properties of native coronary arteries. Moreover, the individual leaflet's biomechanics, including the fluttering phenomenon, were unclear. Porcine aortic roots with coronary arteries were explanted (n=5) and underwent VSARR using SG, VG, ACP, and SMOD for evaluation in an ex vivo left heart flow loop simulator. Additionally, 762 patients who underwent VSARR from 1993 through 2022 at our center were retrospectively reviewed. Analysis of variance was performed to evaluate differences between different conduit configurations, with post hoc Tukey's correction for pairwise testing. SG demonstrated lower rapid leaflet opening velocity compared with VG (P=0.001) and SMOD (P=0.045) in the left coronary cusp (LCC), lower rapid leaflet closing velocity compared with VG (P=0.04) in the right coronary cusp (RCC), and lower relative opening force compared with ACP (P=0.04) in the RCC. The flutter frequency was lower in baseline compared with VG (P=0.02) and in VG compared with ACP (P=0.03) in the LCC. Left coronary artery mean flow was higher in SG compared with SMOD (P=0.02) and ACP (P=0.05). Clinically, operations using SG compared with sinus-containing graft was associated with shorter aortic cross-clamp and cardiopulmonary bypass time (P<0.001, <0.001). SG demonstrated hemodynamics and biomechanics most closely recapitulating those from the native root with significantly shorter intraoperative times compared with repair using sinus-containing graft. Future in vivo validation studies as well as correlation with comprehensive, comparative clinical study outcomes may provide additional invaluable insights regarding strategies to further enhance repair durability.

Reoperation or Aortic Regurgitation Progression after Reimplantation of the Aortic Valve (David's Procedure) Using the Valsalva Graft.

This study aimed to assess predictors of a composite endpoint (reoperation for aortic valve [AV] failure or aortic regurgitation [AR] grade ≥ 2) after reimplantation of the aortic valve (RAV) using the Valsalva graft. From 2012 to 2021, 112 patients underwent RAV in a single center. Clinical and echocardiographic data were collected retrospectively. Cox regression analysis was used to identify predictors of the composite endpoint. Kaplan-Meier methods were used for time-to-event analysis. Median (interquartile range) age was 52 years (44, 62). Nineteen patients (17%) were operated for acute Type A aortic dissection, and the remainder for aortic root aneurysm, 60 mm or larger in 12/112 (11%). Thirty-day mortality was 1/112 (1%). During follow-up, four patients (3.6%) were reoperated for AV failure, and another nine patients (8.1%) developed AR grade ≥ 2. Overall estimated freedom from reoperation or AR grade ≥ 2 was 87% (95% confidence interval: 76-93%) at 5 years. Significantly lower estimated 5-year freedom from the composite endpoint was found in cases with simultaneous aortic valve repair (AVr; 77 vs. 90%, p = 0.007) and nearly significant for large (≥ 6 cm) aortic root diameter (82 vs. 87%, p = 0.055). In Cox's analysis, aortic root diameter and simultaneous AVr were independent predictors for the composite endpoint. Outcomes (survival, reoperation, freedom from AR grade ≥ 2) with RAV were good up to 11-year follow-up. Larger aortic root diameter and simultaneous AVr were identified as predictors for reoperation or AR grade ≥ 2. Long-term follow-up remains necessary to confirm adequate AV function.

From Leonardo to the Valsalva graft: the physics behind valve-sparing aortic root replacement.

Journal Article Accepted manuscript From Leonardo to the Valsalva graft: the physics behind valve-sparing aortic root replacement Get access Giacomo Murana, MD, PhD, Giacomo Murana, MD, PhD Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna Corresponding author: Dr. Giacomo Murana, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy. Tel: 0039 051 2143361 Fax: 0039 051 345990. e-mail: g.murana@hotmail.com; giacomo.murana@aosp.bo.it Search for other works by this author on: Oxford Academic PubMed Google Scholar Davide Pacini, MD, PhD Davide Pacini, MD, PhD Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di BolognaDepartment of Experimental, Diagnostic and Specialty Medicine, DIMES, University of Bologna, Bologna Search for other works by this author on: Oxford Academic PubMed Google Scholar European Journal of Cardio-Thoracic Surgery, ezad094, https://doi.org/10.1093/ejcts/ezad094 Published: 13 March 2023 Article history Received: 06 March 2023 Accepted: 11 March 2023 Published: 13 March 2023

Twenty-year experience of aortic valve reimplantation using the Valsalva graft: a successful technique with well-made device!

The introduction of the aortic valve (AV) reimplantation, also called David procedure, by David and Feindel in 1992 have placed a milestone for AV sparing [1]. This, one of the most 2 important valve-sparing aortic root replacement operations became the standard technique for patients with aortic root aneurysm with or without AV regurgitation with excellent short- and long-term results [2]. Over the years, the surgical technique of AV reimplantation has evolved significantly from the originally described technique aiming to mimic the anatomical form of the aortic root. Many modifications, including the ‘so-called’ David I–V operations, using different techniques such as plication stitches to create pseudo-/neo-sinuses [3, 4], 2 cylindrical grafts [5] or even special anatomically designed bulged grafts [6] have been described. In this issue of the European Journal of Cardiothoracic Surgery, Chirichilli et al. describe their 20-year-long experience with AV reimplantation using the Gelweave Valsalva graft Vascutek Ltd, Terumo Company (Renfrewshire, Scotland, UK) in 265 patients with aortic root aneurysm with or without AV regurgitation [7]. This device has been designed and invented by the senior author of the current article De Paulis [6] at the end of the last millennium and implemented in the routine practise at the beginning of 2000. The presented study belongs to the largest published cohorts describing AV reimplantation with this graft. The early- and long-term outcomes (mean of 7.1 years) are excellent. The overall survival at 15 years was 87.6 ± 3.4% and freedom from cardiac death was excellent and stable at 99.6 ± 0.4% up to 15 years. Freedom from recurrent AR ≥moderate and freedom from reoperation remained stable up to 15 years at 92.2 ± 2.1% and 95.9 ± 1.6%, respectively. In addition, the incidence of infective endocarditis, thromboembolism and haemorrhage was extremely low. Importantly, a clear message that can be derived from this paper is that David procedure using this particular graft is an excellent and durable option for the surgical treatment of the patients with aortic root aneurysm with or without AV regurgitation. The authors also report that long-term results might have improved after the implementation of routine performance of AV analysis with calliper.

Endoscopic evaluation technique using a camera port for valve-sparing root reconstruction.

Intraoperative aortic valve evaluation should be accurate in valve-sparing root replacement to minimize postoperative aortic valve regurgitation. Ascending aorta de-clamping and weaning of cardiopulmonary bypass are required in intraoperative transoesophageal echocardiography. Aortic valve endoscopy aids in the magnification of structures and enables image sharing within the operative team. While a rigid endoscope and saline infusion line are directly inserted from the Valsalva graft end, a Kelly clamp is needed for graft gap closure, affecting the valve morphology due to graft deformation. The accurate inner pressure of the neo-Valsalva sinus cannot be measured in this method. We propose a technique to accurately evaluate aortic valve conformation using a balloon blunt-tip system that enables aortic valve evaluation under the measured pressure and without Valsalva graft deformation.

Remodeling versus reimplantation in aortic root surgery – comparative results and risk factors for aortic insufficiency

Highlights. The main approaches to the aortic root valve-sparing surgery of are reimplantation and remodeling;The literature review demonstrates either the relative identity of the reimplantation and remodeling clinical outcomes, or the advantage of reimplantation in relation to long-term results.Abstract. In recent decades, valve-sparring methods of aortic root replacement, including reimplantation and remodeling, as well as their modifications, have been developed and put into widespread practice. The effectiveness and durability of these two approaches is the subject of discussions in the modern cardiac surgery community. The global experience in performing remodeling and reimplantation procedures allows for a comprehensive literature review to compare the results of these approaches. The presented review is devoted to the comparison of surgical aspects and clinical outcomes of reimplantation and remodeling techniques, the analysis of the feasibility of restoring the physiological architectonics of the aortic root in valve-sparring operations using Valsalva grafts, as well as the assessment of risk factors for residual aortic insufficiency after such interventions. The search strategy included the analysis of international (PubMed, Scopus, Embase) databases for the following keywords: “reimplantation versus remodeling for aortic root valve-sparring procedures”, “David procedure versus Yacoub procedure”, “Valsalva graft for aortic root valve-sparring procedures”, “Valve-sparing aortic root repair with an anatomically shaped sinus prosthesis”. Literature analysis demonstrates either the relative identity of early and long-term results of reimplantation and remodeling procedures, or the advantage of reimplantation in terms of freedom from late mortality and residual aortic insufficiency. Preservation of the physiology of the aortic root by implantation of Valsalva grafts or remodeling provides better hemodynamics and reduces stress on the leaflets, however, these postulates run counter to the data of clinical studies analyzing postoperative outcomes and demonstrating the lack of advantages of Valsalva grafts over linear prostheses in terms of freedom from aortic valve surgery. Residual postoperative regurgitation of a mild degree, a decrease in the effective height below 9 mm and additional interventions on the leaflets are reliable factors of significant aortic insufficiency in the long-term period after valve-sparring operations on the aortic root.

Valve-Sparing Aortic Root Replacement Technique: Valsalva Graft versus Two Straight Tubular Grafts.

There are many variations in valve-sparing aortic root replacement techniques. Our aim is to determine the impact of the graft on mid-term outcomes: Valsalva graft vs. two straight tubular grafts. From 2004 to 2020, 332 patients underwent valve-sparing aortic root replacement with either a Valsalva graft (Valsalva group: n = 270) or two straight tubular grafts (two-graft group: n = 62). Data were obtained through chart review and the National Death Index. Primary outcomes were mid-term survival and freedom from reoperation. The preoperative characteristics of the groups were similar, but the two-graft group had more type A dissections (32% vs. 19%) and emergent operations (26% vs. 15%) and was younger (45 vs. 50 years). Intraoperatively, the groups were similar, but the two-graft group had longer cross-clamp (245 vs. 215 minutes) and cardiopulmonary bypass times (284 vs. 255 minutes). Postoperative complications including reoperation for bleeding, stroke, pacemaker implantation, and renal failure were slightly more frequent in the Valsalva group, but the differences were not significant. Operative mortality was similar between the Valsalva and two-graft groups (0.7% vs. 0%). Five-year survival in the two-graft group was 100% compared to 96% in the Valsalva group (p=0.56). Five-year freedom from reoperation in the two-graft group was 100% compared to 93% in the Valsalva group (p=0.29). The Valsalva and two-graft techniques both have excellent short- and mid-term outcomes. The two-graft technique might have slightly better survival and freedom from reoperation, but a larger sample size and longer follow-up are needed to determine if these advantages are significant.

Twenty-year experience of aortic valve reimplantation using the Valsalva graft.

Over the past 20 years, valve-sparing aortic root replacement has aroused increasing interest because of a progressive attitude towards the preservation of natural tissue. Aortic reimplantation is the most used technique to spare the valve, allowing simultaneously aortic root replacement and aortic annular stabilization. The reimplantation into a graft with sinuses guarantees an optimal anatomic and functional reconstruction with established good results at 15 years. The aim of this study is to report the world longest follow-up (up to 20 years) of aortic valve reimplantation using the Valsalva graft. From February 2000 to December 2021, 265 consecutive patients with aortic root aneurysm received aortic valve reimplantation using the Valsalva graft. From 2018, leaflet plication with the routine use of calliper was performed. For each patient, we performed both intraoperative and post-procedural transoesophageal echocardiography. All patients were followed with clinical assessment and echocardiography. The mean duration of follow-up was 85 ± 63 months. The study cohort had a median age of 55 ± 18 and 87.2% were male. The aortic root aneurysm was associated to bicuspid aortic valve in 18.9% of patients and to Marfan syndrome in 10.6% of cases. 55.9% had an aortic regurgitation ≥ 2+. Overall survival at 15 was 87.6 ± 3.4. Freedom from cardiac death was stable at 99.6 ± 0.4 at 5, 10 and 15 years. Freedom from recurrent AR ≥3+ and freedom from reoperation remained stable at 10 and 15 years at 92.2 ± 2.1 and 95.9 ± 1.6, respectively. There was a minimal incidence of infective endocarditis (0.8%), thromboembolism (2.2%) and haemorrhage (2.0%). Six out of 7 patients requiring reoperation had surgery in the first period of our experience (last in 2004). Early suboptimal results had a negative effect on residual aortic regurgitation. Moreover, we hypothesized that the routine use of calliper may have contributed to a further improvement of the outcome, even if these data need to be confirmed by a longer follow-up. The first long-term follow-up after aortic valve reimplantation using the Valsalva graft demonstrated excellent results. These long-term results gradually improved with learning curve, remaining stable during the second decade of observation. The systematic use of calliper may have contributed to a further improvement of the outcome.

Abstract 11145: Biomechanical Engineering Analysis of Leaflet Kinematics and Native Coronary Flow After Valve-Sparing Aortic Root Replacement Using Four Graft Configurations

Introduction: Different ex vivo root biomechanics after valve-sparing aortic root replacement (VSARR) using several graft configurations have been described. The impact of graft choice on each cusp’s kinematics and native coronary flow remains unclear. The objective was to analyze valve kinematics and coronary flow after VSARR using 4 graft configurations in a 3D-printed heart simulator ( Fig A ).[YZ1] Methods: Porcine aortic roots with coronary arteries were explanted (n = 5). Native roots served as controls ( Fig B ). Each sample underwent VSARR using straight graft (SG), Valsalva graft (VG), anti-commissural plication (ACP), and Stanford modification (SMOD) in a random order ( Fig C-G ). Hemodynamics and videometric data were analyzed ( Fig H, I ). Results: SG showed the lowest regurgitant fraction (2.8 ± 1.5 %) compared to control (6.3 ± 3.9 %, p = .0002), VG (12.2 ± 3.6 %, p = .002), ACP (12.9 ± 1.3 %, p = .001), and SMOD (12.2 ± 3.0 %, p = .001, Fig J, K ). The left coronary artery flow was higher in SG (0.68 ± 0.16 L/min) compared to VG (0.55 ± 0.22 L/min, p = 0.05) and SMOD (0.51 ± 0.23 L/min, p = 0.05, Fig L ). The right coronary artery flow was higher in SG (0.20 ± 0.10 L/min) compared to VG (0.07 ± 0.04 L/min, p = 0.04) and SMOD (0.08 ± 0.05 L/min, p = 0.04, Fig M ). SG (26.5 ± 17.6 cm/s) compared to VG (48.3 ± 19.0 cm/s, p = .001) and SMOD (39.5 ± 10.1 cm/s, p = .05) showed lower rapid opening velocity in the left coronary cusp (LCC). SG (8.1 ± 6.2 cm/s) compared to VG (15.0 ± 10.6 cm/s, p = .04) showed lower rapid closing velocity in the right coronary cusp. The VG (17.7 ± 9.7 Hz) had higher flutter frequency in the LCC compared to control (11.9 ± 4.1 Hz, p = .02). The SG (11.9 ± 4.5 dB/Hz) compared to ACP (16.4 ± 4.7 dB/Hz, p = .01) showed lower flutter power in the LCC. Conclusions: Compared to other configurations, SG had the most optimal hemodynamics, native coronary flow, and leaflet kinematics. Further in vivo validation studies should be performed to evaluate flow dynamics in the root and assess for clinical applicability.

Modified composite-graft technique for aortic root replacement.

This report describes a novel modification of a self-assembled composite graft to replace the aortic root and left ventricular outflow tract (LVOT). This technique enables the implantation of a larger valve than conventional ways and simultaneous reconstruction of LVOT. This technique comprises Inspiris Resilia aortic valve and Gelweave Valsalva graft. By placing the valve in the sinus portion of the graft, the bioprosthesis that is 1mm smaller than the graft can be accommodated, providing a proper length of the collar for LVOT reconstruction. This technique is useful for patients who require redo-aortic root replacement and have restricted LVOT.

Surgical Repair of a Sinus of Valsalva Aneurysm.

A surgically challenging case of an unruptured Sinus of Valsalva aneurysm (SoVA) with severe aortic regurgitation (AR) due to cusp prolapse is presented. Sinus reconstruction with a patch cut out from the sinus portion of a Gelweave Valsalva graft (Terumo Vascutek) was performed. Intraoperative measurements showed insufficient effective height of the right coronary cusp; therefore, cusp plication and pericardial patch augmentation of the right coronary cusp were performed with satisfying result.

Aortic valve reimplantation in patients with connective tissue syndromes: A 15-year follow-up.

The goal of this study was to analyse early- and long-term outcomes of aortic valve reimplantation (David operation) in patients with heritable thoracic aortic disease. This is a retrospective observational analysis using data from a prospectively maintained surgical database from March 2004 to April 2021. Patients with heritable thoracic aortic disease were included in the study. A total of 157 patients with aortic root aneurysm with the diagnosis of heritable thoracic aortic disease received the David procedure. Marfan syndrome was found in 143 (91.1%) patients, Loeys-Dietz in 13 and Ehler-Danlos in 1 patient. The median age was 35.0 (IQR: 17.5) years and the median ascending aorta diameter in the Valsalva sinuses was 48 mm (IQR: 4). A Valsalva graft was used in 8 patients; the David V technique was performed in the rest of the cases. The median follow-up time was 7.3 years [standard deviation: 0.58, 95% confidence interval (CI): 6.12-8.05]. Only 2 patients died during the follow-up period. The overall survival was 99% (95% CI: 95%; 99%); 98% (95% CI: 92%; 99%); and 98% (95% CI: 92%; 99%) at 5, 10 and 15 years. Freedom from significant aortic regurgitation (AR> II), reintervention and postoperative type-B dissection was 90% (95% CI: 77%; 95%), 96% (95% CI: 91%; 99%) and 87% (95% CI: 68%; 95%) at 15 years, respectively. No differences were found in any outcome between Marfan syndrome and Loeys-Dietz syndrome. No statistically significant differences in survival were found when we compared expected gender- and age-specific population survival values. The David operation is an excellent option for the treatment of patients with heritable thoracic aortic disease and dilatated aortic root. Surgical expertise in referral centres is essential to achieve the best long-term results.

Clinical Outcomes Using Freestyle Valve–Valsalva Graft Composite Conduit for Aortic Root Replacement

BackgroundWe reviewed the clinical outcomes of a novel method of aortic root replacement using a self-constructed tissue valve conduit composed of a Freestyle subcoronary valve sewn into a Valsalva graft. MethodsFrom 2005 to 2020, 523 patients had aortic root replacement operations using a self-constructed Freestyle subcoronary–Valsalva graft tissue valve conduit. Median patient age was 62 years (interquartile range [IQR] 54-70), and 430 (82%) were men. Primary outcomes were mortality and the need for reoperation. Multivariable regression analyses were performed to identify risk factors for mortality and reoperation. ResultsUrgent procedures comprised 48.37% of cases, and 29.26% were reoperative procedures. Concomitant ascending aorta replacement, hemiarch replacement, and total arch replacement were required in 348 (67%), 227 (44%), and 40 (8%) patients, respectively. Cardiopulmonary bypass and cross-clamp times were 189 minutes (IQR, 164-218) and 166 minutes (IQR, 145-191), respectively. Early mortality was 7.7% (40), and 5- and 10-year survival rates were 83% and 71%, respectively. At the last echocardiogram follow-up left ventricular ejection fraction, left ventricular end-diastolic diameter, degree of aortic insufficiency, and mean aortic valve gradient were significantly improved from baseline (P < .001). Increasing age, peripheral artery disease, tobacco use, increased preoperative creatinine, and prior aortic valve surgery were risk factors for both mortality and the composite outcome (P < .02). ConclusionsIn a complex patient population aortic root replacement using a self-constructed composite tissue valve conduit comprising a Freestyle subcoronary valve–Valsalva graft can be performed with excellent operative and 10-year outcomes. Midterm survival was acceptable, and valve durability was outstanding with an exceedingly low incidence for valve reintervention.

Aortic Root Replacement of Small Roots to Prepare for Transcatheter Aortic Valve Replacement

Small aortic root is a significant limitation of optimal hemodynamics for surgical aortic valve replacement due to a small annulus and application of transcatheter aortic valve replacement due to low coronary ostia and limited space at the root. We sutured a bioprosthetic valve that was up-sized by 2 to 3 valve sizes in the skirt portion of a Valsalva graft (Terumo Medical Corp) and implanted the coronary button high, close to sinotubular junction, to achieve optimal hemodynamics and prepare patients for future transcatheter aortic valve replacement.

Aortic root anatomy after aortic valve reimplantation

ObjectiveDuring the last decade, special concerns have been raised about the anatomic relationships among the sinotubular junction, ventricular-aortic junction, and virtual basal ring to improve the results of root reconstruction. The aim of this study is to evaluate the in vivo anatomy of the aortic root after reimplantation with the Valsalva graft and the anatomic relationship between its components. MethodsWe analyzed 10 consecutive patients with tricuspid aortic valves who underwent reimplantation with the Valsalva graft between September and December 2019. Surgical clips were applied as markers at the level of proximal annular knots and at the distal reimplanted commissures on the neo-sinotubular junction. Electrocardiogram-gated computed tomography scan of the aortic root was performed. Coordinates of the markers were exported on a 3-dimensional modeling software, and the distances between the virtual basal ring and the Dacron graft basal landmarks were measured. ResultsThe mean heights of Dacron graft basal landmarks from virtual basal ring were right-left commissure 7.1 ± 5.1 mm; right sinus 4.7 ± 4.1 mm; right-noncoronary commissure 2.8 ± 2.2 mm; noncoronary sinus 1.4 ± 1.6 mm; left-noncoronary commissure 2.2 ± 2.3 mm; and left sinus 2.0 ± 0.9 mm. The mean planar distances of basal Dacron graft landmarks from virtual basal ring (thickness) were right-left commissure 5.3 ± 3.1 mm; right sinus 2.8 ± 1.4 mm; right-noncoronary commissure 2.2 ± 1.5 mm; noncoronary sinus 1.5 ± 1.5 mm; left-noncoronary commissure 1.3 ± 1.0 mm; and left sinus 3.4 ± 2.5 mm. ConclusionsAfter reimplantation, despite a complete dissection of the root, slight asymmetry of graft proximal seating exists. The inner annuloplasty is on the virtual basal ring, and the proximal edge of the Dacron graft is on the ventricular-aortic junction at a slightly different thickness and height along the annular circumference. At the level of the right sinus and left/right commissure, the Dacron graft is higher than the virtual basal ring and the relative wall thickness is increased. The annular stabilization is unaffected.

The Skirt and Collar of The Valsalva Graft: One Dress Fits All

In the original pre-formed Valsalva graft, the skirt is the defining feature. It is a self-expanding portion, obtained by 90° rotation of the Dacron fabric corrugation with respect to the rest of the graft. Due to this manufacturing feature, the skirt length is equal to the graft diameter and, once pressurized, it expands by 25-30% (up to 10 mm) from the nominal size. Proximal to this bulged portion, a small collar completes the prosthesis. By virtue of this anatomical design, the Valsalva graft is recommended for most aortic root surgeries including valve-sparing and Bentall procedures. The skirt, by recreating the pseudo-sinuses, represents the key feature of the graft when used for aortic valve-sparing procedures (remodeling and reimplantation). However, in the Bentall procedure, the graft collar is an important feature because it is useful to attach the Valsalva graft to the valve prosthesis sewing ring when making a valved conduit. Moreover, once the graft is pressurized, the whole volume of the skirt better accommodates the struts and the leaflets of biological and mechanical prostheses. Furthermore, the expanded skirt reduces the distance and the tension on the coronary button anastomosis, increasing safety and possibly reducing complication rates. This review demonstrates the versatility of the Valsalva graft in various scenarios of aortic root surgery, with special emphasis on different uses of the skirt and the collar.

Optimized Use of the “Skirt” of the Valsalva Graft for the Completion Bentall Procedure

This report discusses the case of a patient with an aortic root aneurysm who had previously undergone aortic valve replacement with a large mechanical prosthesis that proved to be normally functioning at the time of reoperation. This report describes a technique of replacing the aortic root while retaining the existing aortic valve, similar to the completion Bentall procedure, using a 32-mm Valsalva graft by suturing the skirted portion of the graft to the sewing ring of the mechanical valve. The ability of the skirt to increase its diameter is the key to this approach.