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De Paulis R, Torre M, Scaffa R. Straight tube versus Valsalva graft for valve-sparing operation. Ann Cardiothorac Surg 2023; 12:358-360. [PMID: 37554711 PMCID: PMC10405343 DOI: 10.21037/acs-2023-avs2-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/30/2023] [Indexed: 08/10/2023]
Affiliation(s)
- Ruggero De Paulis
- Department of Cardiac Surgery, European Hospital, Unicamillus University, Rome, Italy
| | - Mario Torre
- Department of Cardiac Surgery, University Federico II, Naples, Italy
| | - Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Unicamillus University, Rome, Italy
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2
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Chirichilli II, Ricci A, Weltert L, Torre M, Irace F, Scaffa R, Folino G, Salica A, D'Aleo S, Wolf LG, Fusca S, Bellisario A, Marra G, Andreis M, Ciani C, Forcina S, De Paulis R. Aortic Annuloplasty: Focus on the Use of an External Teflon Ring. Surg Technol Int 2023; 42:sti42/1679. [PMID: 37466920 DOI: 10.52198/23.sti.42.cv1679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Aortic annuloplasty has been clearly demonstrated to have a protective influence in aortic valve repair. Over the past 20 years, different annuloplasty concepts have been proposed by different groups. However, the most appropriate approach to enable long-term annular stability remains highly controversial. The aim of this article is to give a general overview of all types of aortic annuloplasty, particularly focusing on the use of an external Teflon ring, as proposed by our group. In this technique, external root dissection is performed in the same fashion as for reimplantation; the only difference is that it is necessary to go below the coronary ostia take-off. A series of pledgeted sutures (usually between 6 and 9 sutures) are placed at the level of the virtual basal ring. The external ring is made using a Teflon strip with a length of 8 to 9 cm, to reduce the annulus to a diameter of between 21 and 23 mm. The sub-annular sutures are then passed at the appropriate level through the Teflon strip and the strip is parachuted outside the aortic root base, passing under the coronary ostia. The two ends of the Teflon strip are tied at the level of the non-coronary sinus. Aortic annuloplasty is a crucial step to improve valve competence and stabilization. While several techniques offer good mid- to long-term results, annuloplasty with an external Teflon ring appears to be a simple and effective alternative to guarantee stable root diameters. Longer follow-up studies are needed to confirm the mid- to long-term results.
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Affiliation(s)
| | | | - Luca Weltert
- Cardiac Surgery Department, European Hospital, Rome, Italy
- Unicamillus, International Medical University in Rome, Rome, Italy
| | - Mario Torre
- Cardiac Surgery Department, European Hospital, Rome, Italy
- Cardiac Surgery Department, University of Naples Federico II, Naples, Italy
| | - Francesco Irace
- Cardiac Surgery Department, A. O. San Camillo, Forlanini, Rome, Italy
| | | | - Giulio Folino
- Cardiac Surgery Department, European Hospital, Rome, Italy
| | - Andrea Salica
- Cardiac Surgery Department, European Hospital, Rome, Italy
| | | | | | - Samuel Fusca
- Cardiac Surgery Department, European Hospital, Rome, Italy
| | | | - Giulia Marra
- Cardiac Surgery Department, European Hospital, Rome, Italy
- Cardiac Surgery Department, University of Padua, Padua, Italy
| | - Marco Andreis
- Cardiac Surgery Department, European Hospital, Rome, Italy
- Cardiac Surgery Department, University of Padua, Padua, Italy
| | - Camilla Ciani
- Cardiac Surgery Department, European Hospital, Rome, Italy
- Cardiac Surgery Department, University of Padua, Padua, Italy
| | - Sara Forcina
- Cardiac Surgery Department, European Hospital, Rome, Italy
| | - Ruggero De Paulis
- Cardiac Surgery Department, European Hospital, Rome, Italy
- Unicamillus, International Medical University in Rome, Rome, Italy
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Chirichilli I, Scaffa R, Irace FG, Salica A, Weltert LP, D'Aleo S, Chiariello L, De Paulis R. Twenty-year experience of aortic valve reimplantation using the Valsalva graft. Eur J Cardiothorac Surg 2023; 63:6965028. [PMID: 36579861 DOI: 10.1093/ejcts/ezac591] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/22/2022] [Accepted: 12/28/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Ilaria Chirichilli
- Department of Cardiac Surgery, European Hospital, Rome, Italy.,Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Francesco Giosuè Irace
- Department of Cardiac Surgery, European Hospital, Rome, Italy.,Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy.,Department of General and Specialized Surgery "Paride Stefanini", Sapienza University, Rome, Italy
| | - Andrea Salica
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Luca Paolo Weltert
- Department of Cardiac Surgery, European Hospital, Rome, Italy.,Department of Statistics, UniCamillus International University of Health Sciences, Rome, Italy
| | | | | | - Ruggero De Paulis
- Department of Cardiac Surgery, European Hospital, Rome, Italy.,Chair of Cardiac Surgery, UniCamillus, International University of Health Sciences, Rome, Italy
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Folino G, Salica A, Scaffa R, Irace FG, Weltert LP, Bellisario A, Gerosa G, De Paulis R. Mitral repair of myxomatous valves with simple annuloplasty: a follow-up up to 12 years. Eur J Cardiothorac Surg 2022; 63:6957089. [PMID: 36548399 DOI: 10.1093/ejcts/ezac580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/29/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Diffuse myxomatous mitral valve degeneration (DMD) represents a challenge in the reparative mitral valve surgery. A subgroup of patients with symmetrical DMD can be effectively treated with a simple band-annuloplasty with good early and mid-term results. Here, we evaluate the long-term outcomes in terms of freedom from reoperation, recurrence of moderate or severe mitral regurgitation (MR) and overall survival. METHODS Between April 2006 and December 2020, patients with DMD causing severe MR and the echocardiographic features of symmetrical bileaflet prolapse, central regurgitant jet(s), annular dilation and no chordal ruptures were treated using a simple annuloplasty with a semi-rigid band. These patients were prospectively collected and retrospectively analysed. RESULTS Seventy-five patients were enrolled. The mean clinical follow-up time was 104 [standard deviation (SD): 43] months, and echocardiographic follow-up time was 95 (SD: 43) months. The mean age was 54 (SD: 15) years, and 56% were females. Long-term overall survival was 98.2% [standard error (SE): 1.8], 93.7% (SE: 4.7) and 93.7% (SE: 4.7) at 4, 8 and 12 years, respectively. The freedom from reoperation was 100% at 4 and 8 years and 94.1% (SE: 5.7) at 12 years. The freedom from recurrent moderate or severe MR was 98.3% (SE: 1.7), 98.3% (SE: 1.7) and 92.8% (SE: 5.5) at 4, 8 and 12 years, respectively. CONCLUSIONS Mitral repair with the simple band-annuloplasty for the treatment of MR due to symmetrical DMD seems to be stable and effective in the long term.
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Affiliation(s)
- Giulio Folino
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Andrea Salica
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Francesco Giosuè Irace
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | | | | | - Gino Gerosa
- Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padova, Italy
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De Paulis R, Folino G, Scaffa R. The percutaneous coronary angioplasty gets better, but the surgical coronary artery bypass does not stay behind. Eur Heart J Suppl 2022; 24:I81-I83. [PMCID: PMC9653154 DOI: 10.1093/eurheartjsupp/suac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Coronary artery bypass grafting remains one of the most frequently performed cardiac operations, with well-established prognostic benefits in patients with multivessel coronary artery disease and left main disease. Despite an increasingly higher patients’ risk profile, the results of this procedure have significantly improved over time, with an evident and striking decrease in operative mortality and peri-operative complications. A fair amount of technical and technological refinements has further improved the short- and long-term results of coronary artery bypass surgery. The improvements in the beating heart coronary surgery and aortic ‘no-touch’ technique, in the appropriate use of conduits (bilateral internal mammary artery, radial artery, and composite conduits configuration), and in the optimization of venous grafts’ patency are reviewed.
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Affiliation(s)
- Ruggero De Paulis
- Division of Cardiac Surgery - European Hospital, and UniCamillus University , Rome
| | - Giulio Folino
- Division of Cardiac Surgery - European Hospital, and UniCamillus University , Rome
| | - Raffaele Scaffa
- Division of Cardiac Surgery - European Hospital, and UniCamillus University , Rome
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Folino G, Scaffa R, Salica A, De Paulis R. An Aortic Valve 21 Years After Repair. Eur J Cardiothorac Surg 2022; 62:6671843. [PMID: 35984313 DOI: 10.1093/ejcts/ezac423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Giulio Folino
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Andrea Salica
- Department of Cardiac Surgery, European Hospital, Rome, Italy
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Irace FG, Chirichilli I, Folino G, Salica A, Guerrieri Wolf L, Scaffa R, D'Aleo S, Weltert LP, De Paulis R. Reimplantation versus aortic ring annuloplasty in bicuspid valve with borderline aortic root ectasia. JTCVS Tech 2022; 15:36-45. [PMID: 36276689 PMCID: PMC9579730 DOI: 10.1016/j.xjtc.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/05/2022] [Indexed: 11/01/2022] Open
Abstract
Objective Methods Results Conclusions
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8
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Ricci A, Weltert LP, Lucertini G, Ciccarelli G, Scaffa R, Salica A, D'Aleo S, Guerrieri-Wolf L, Fusca S, Bellisario A, De Paulis R. Biological Valves Impervious to Calcification: Is this Holy Grail a Cup Ready to Drink? Surg Technol Int 2022; 40:235-240. [PMID: 35179734 DOI: 10.52198/22.sti.40.cv1496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
An indefinitely lasting bioprosthesis that does not require anticoagulation treatment is the holy grail of substitutive heart surgery. However, this goal is not yet in sight with the present state of technology. Over the past few years, tremendous advances have been achieved regarding tissue anticalcification processes, hemodynamic performance and future-proofing by ensuring compatibility with transcatheter valve-in-valve procedures. The Inspiris Resilia valve (Edwards Lifesciences, Irvine, CA) was designed to incorporate all of these enhancements. It is now leaving the experimental phase and is being tested in the real world. We present here a comprehensive review of the evolution of biological prostheses, details of new anticalcification technologies, and early results of published studies as well as the experience at the European Hospital (Rome, Italy), the site of the first European implant and a leading center in various protocols. In our two years of experience with the Inspiris Resilia, there have been no cases of structural valve deterioration, endocarditis, detachment or periprocedural complication, and gradients seem to be superior to those with the previous generation of Edwards valves. While longer-term experience is clearly needed, the results thus far are encouraging.
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Affiliation(s)
| | | | | | | | | | - Andrea Salica
- European Hospital, Heart Surgery Division, Rome, Italy
| | | | | | - Samuel Fusca
- European Hospital, Heart Surgery Division, Rome, Italy
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9
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Henmi S, Scaffa R, Folino G, De Paulis R. Simple completion Bentall procedure of preserving aortic bioprosthesis after aortic valve replacement. JTCVS Tech 2022; 14:66-68. [PMID: 35967236 PMCID: PMC9366610 DOI: 10.1016/j.xjtc.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/04/2022] [Accepted: 04/18/2022] [Indexed: 12/03/2022] Open
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10
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Folino G, Scaffa R, Salica A, Weltert L, D'Aleo S, Guerrieri L, Irace F, Coscioni E, Gerosa G, De Paulis R. The black root: Aortic valve sparing in alkaptonuria. J Card Surg 2022; 37:1413-1415. [DOI: 10.1111/jocs.16331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/28/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Giulio Folino
- Department of Cardio‐Thoracic and Vascular Sciences University of Padua Padua Italy
| | - Raffaele Scaffa
- Department of Cardiac Surgery European Hospital Rome Italy
- Division of Cardiac Surgery A.O.U. San Giovanni di Dio e Ruggi d'Aragona Salerno Italy
| | - Andrea Salica
- Department of Cardiac Surgery European Hospital Rome Italy
| | - Luca Weltert
- Department of Cardiac Surgery European Hospital Rome Italy
| | - Salvo D'Aleo
- Department of Cardiac Surgery European Hospital Rome Italy
| | | | - Francesco Irace
- Department of General and Specialized Surgery Paride Stefanini Sapienza University Rome Italy
| | - Enrico Coscioni
- Division of Cardiac Surgery A.O.U. San Giovanni di Dio e Ruggi d'Aragona Salerno Italy
| | - Gino Gerosa
- Department of Cardio‐Thoracic and Vascular Sciences University of Padua Padua Italy
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Henmi S, Salica A, Scaffa R, D’Aleo S, Wolf LG, De Paulis R. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac182. [PMID: 35592454 PMCID: PMC9113441 DOI: 10.1093/jscr/rjac182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Cardiac myxoma is the most common primary benign cardiac tumor in adults and right atrial myxoma is a rare observation. We report a case of a 56-year-old woman who presented with dyspnea and diagnosed with a right atrial myxoma. Urgent operation through a right mini thoracotomy was done and myxoma was completely excised. Traditionally, median sternotomy with cardiopulmonary bypass is used for excision of cardiac myxoma. Excision through a mini thoracotomy for patients with right atrial myxoma appear to be safe, feasible and efficacious.
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Affiliation(s)
- Soichiro Henmi
- Correspondence address. Cardiac Surgery Department, European Hospital, Via Portuense 700, Roma 00149, Italy. Tel: +1-240-797-9787; E-mail:
| | - Andrea Salica
- Cardiac Surgery Department, European Hospital, Rome, Italy
- Unicamillus University, Roma, Italy
| | - Raffaele Scaffa
- Cardiac Surgery Department, European Hospital, Rome, Italy
- Unicamillus University, Roma, Italy
| | - Salvatore D’Aleo
- Cardiac Surgery Department, European Hospital, Rome, Italy
- Unicamillus University, Roma, Italy
| | - Lorenzo Guerrieri Wolf
- Cardiac Surgery Department, European Hospital, Rome, Italy
- Unicamillus University, Roma, Italy
| | - Ruggero De Paulis
- Cardiac Surgery Department, European Hospital, Rome, Italy
- Unicamillus University, Roma, Italy
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Scaffa R, Torre M, Longobardi A, Ferrara D, Vassallo MG, Itri F, Coscioni E. Giant Distal Anastomotic Pseudoaneurysm 35 Years after Bentall Operation Mimicking an “Elephant Trunk”. Aorta (Stamford) 2021; 9:193-195. [PMID: 34879402 PMCID: PMC8654511 DOI: 10.1055/s-0041-1732399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We present the case of a giant distal aortic pseudoaneurysm 35 years after a classic mechanical Bentall operation. Computed tomography and coronary angiography showed that this originated from the distal suture line. The proximal suture and coronary ostia appeared to be intact. At reoperation, we found a complete dehiscence of distal suture line: the graft was floating in the pseudoaneurysm, mimicking an “elephant trunk” procedure. This complication suggested a systematic and accurate follow-up of patients who underwent an original Bentall procedure.
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Affiliation(s)
- Raffaele Scaffa
- Division of Cardiac Surgery, Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Mario Torre
- Division of Cardiac Surgery, Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Antonio Longobardi
- Division of Cardiac Surgery, Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - David Ferrara
- Division of Cardiac Surgery, Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Maria G. Vassallo
- Division of Cardiac Surgery, Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Francesco Itri
- Division of Cardiac Surgery, Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Enrico Coscioni
- Division of Cardiac Surgery, Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
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13
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Torre M, Vassallo MG, Longobardi A, Ferrara D, Scaffa R, Spagnuolo M, Bottigliero M, Coscioni E. [The completion Bentall procedure: aortic root and ascending aorta replacement after prior aortic valve replacement]. G Ital Cardiol (Rome) 2021; 22:851-853. [PMID: 34570119 DOI: 10.1714/3666.36516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We describe the case of a patient with an ascending aorta and aortic root aneurysm who underwent aortic valve replacement, 14 years earlier, with a mechanical prosthesis, which was normally functioning at time of reoperation. We describe the "completion Bentall" technique - a modified Bentall technique -, a procedure for prosthesis-sparing aortic root replacement. This technique simplifies the original procedure in reinterventions, reducing complication rates and aortic cross-clamping and cardiopulmonary bypass times, with a good surgical result.
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Affiliation(s)
- Mario Torre
- Divisione di Cardiochirurgia, A.O. OO.RR. San Giovanni di Dio e Ruggi d'Aragona, Salerno - Divisione di Cardiochirurgia, A.O.U. Federico II, Università degli Studi di Napoli Federico II, Napoli
| | | | - Antonio Longobardi
- Divisione di Cardiochirurgia, A.O. OO.RR. San Giovanni di Dio e Ruggi d'Aragona, Salerno
| | - David Ferrara
- Divisione di Cardiochirurgia, A.O. OO.RR. San Giovanni di Dio e Ruggi d'Aragona, Salerno
| | - Raffaele Scaffa
- Divisione di Cardiochirurgia, A.O. OO.RR. San Giovanni di Dio e Ruggi d'Aragona, Salerno
| | - Mattia Spagnuolo
- Divisione di Cardiochirurgia, A.O. OO.RR. San Giovanni di Dio e Ruggi d'Aragona, Salerno - Divisione di Cardiochirurgia, A.O.U. Federico II, Università degli Studi di Napoli Federico II, Napoli
| | - Matteo Bottigliero
- Divisione di Cardiochirurgia, A.O. OO.RR. San Giovanni di Dio e Ruggi d'Aragona, Salerno
| | - Enrico Coscioni
- Divisione di Cardiochirurgia, A.O. OO.RR. San Giovanni di Dio e Ruggi d'Aragona, Salerno
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14
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Scaffa R, Weltert L, Salica A, De Paulis R. The Skirt and Collar of The Valsalva Graft: One Dress Fits All. Surg Technol Int 2021; 38:271-277. [PMID: 33724434 DOI: 10.52198/21.sti.38.cv1390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy
- Division of Cardiac Surgery, A.O.U. San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Luca Weltert
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Andrea Salica
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Ruggero De Paulis
- Department of Cardiac Surgery, European Hospital, Rome, Italy
- UniCamillus, International Medical University, Rome, Italy
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15
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Scaffa R, Salica A, Weltert L, Irace FG, Wolf LG, D'Aleo S, Bellisario A, De Paulis R. Optimized use of the "skirt" of the Valsalva graft for the completion Bentall. Ann Thorac Surg 2021; 112:e303-e305. [PMID: 33689742 DOI: 10.1016/j.athoracsur.2021.02.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/08/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
We report the case of a patient with an aortic root aneurysm who had previously undergone aortic valve replacement with a large mechanical prosthesis which proved to be normally functioning at the time of reoperation. We describe a new 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 was the key of this approach.
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Affiliation(s)
- Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy; Division of Cardiac Surgery, A.O.U. San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy.
| | - Andrea Salica
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Luca Weltert
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Francesco Giosuè Irace
- Department of Cardiac Surgery, European Hospital, Rome, Italy; Department of General and Specialized Surgery "Paride Stefanini", Sapienza University, Rome, Italy
| | | | - Salvo D'Aleo
- Department of Cardiac Surgery, European Hospital, Rome, Italy
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Folino G, Scaffa R, Salica A, De Paulis R. Fate of a coronary artery intramural haematoma complicating aortic root surgery: a case report. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 33426446 PMCID: PMC7780453 DOI: 10.1093/ehjcr/ytaa285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/11/2020] [Accepted: 07/29/2020] [Indexed: 11/29/2022]
Abstract
Background Coronary intramural haematoma (CIH) is an uncommon but potentially life-threatening complication during aortic root surgery (such as Bentall procedure). Depending on its extension it can lead to cardiogenic shock. Documented reports of this complication are lacking in literature. Case summary In the report we present a case of CIH and its management and we show a stepwise imaging of the healing process that gives an insight of the fate of CIHs. Discussion This case raises awareness of CIH as differential diagnosis for myocardial ischaemia during aortic root surgery. It underlines the effectiveness of immediate surgical revascularization, highlights the potential temporary role of coronary artery bypass graft that can stabilize the acute coronary syndrome and may give time to the CIH to reabsorb and native coronary circulation to re-establish.
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Affiliation(s)
- Giulio Folino
- Department of Cardiac Surgery, University of Padua, Via Giustiniani, 2, 35128 Padova, Italy
| | - Raffaele Scaffa
- Department of Cardiac Surgery, San Giovanni di Dio e Ruggi d'Aragona, Largo Città di Ippocrate, 84131 Salerno, Italy
| | - Andrea Salica
- Department of Cardiac Surgery, European Hospital, Via Portuense 700, 00181 Rome, Italy
| | - Ruggero De Paulis
- Department of Cardiac Surgery, European Hospital, Via Portuense 700, 00181 Rome, Italy
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Weltert LP, Wolf LG, Garufi L, Scaffa R, Salica A, Ricci A, Irace FG, Fusca S, D'Aleo S, Chirichilli I, Bellisario A, de Paulis R. External Stents for Vein Grafts in Coronary Artery Bypass Grafting: Targeting Intimal Hyperplasia. Surg Technol Int 2020; 35:197-201. [PMID: 32120449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Progressive saphenous vein graft (SVG) failure remains a key limitation to the long-term success of coronary artery bypass grafting (CABG). SVG disease after the first year is dominated by intimal hyperplasia, which predisposes the SVG to thrombosis and accelerated atherosclerosis. The objective of this study was to review and summarize the latest experimental and clinical data on the use of mechanical external stents for vein grafts. METHODS In January 2020, the PubMed database was searched using the terms "external stent", "CABG", "saphenous vein graft" and "intimal hyperplasia". The results were reviewed and only randomized experimental and clinical studies that analyzed the effect of external stenting on venous intimal hyperplasia were included in the analysis, together with studies that investigated the clinical benefit of external stenting. RESULTS Eight experimental and four clinical trials met the search criteria. Controlled trials in different large animal models concluded that external stenting significantly reduced intimal hyperplasia 3-6 months post implantation, and reduced both thrombosis rates and the development of lumen irregularities. Data from randomized controlled trials with a follow-up period of 1-4.5 years supported the pre-clinical findings and demonstrated that external stents significantly reduced vein graft disease. CONCLUSION Strong evidence indicates that supporting the vein with external stents is safe and leads to clear advantages at both the anatomical and cellular levels. With the further accumulation of consistent positive results, external stenting of SVG may become the standard of care in future CABG.
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Affiliation(s)
- Luca Paolo Weltert
- Heart Surgery Unit, European Hospital, Rome, Italy, Department of Statistics, San Camillus International University for Health Sciences, Rome, Italy
| | | | - Luigi Garufi
- Cardiac Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
| | | | | | | | | | - Samuel Fusca
- Heart Surgery Unit, European Hospital, Rome, Italy
| | | | - Ilaria Chirichilli
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital Rome, Italy
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Chirichilli I, Irace FG, D'Aleo S, Folino G, Weltert LP, Scaffa R, Nardella S, De Paulis R. Long-term follow-up of Bentall procedure using the Perimount bioprosthesis and the Valsalva graft. Interact Cardiovasc Thorac Surg 2020; 30:679-684. [PMID: 32236551 DOI: 10.1093/icvts/ivaa007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 12/11/2019] [Accepted: 01/06/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Bentall procedure is the gold standard for aortic root pathologies when valve repair is not feasible. The development of durable bioprosthetic valves and improved vascular conduits allowed the implementation of bioprosthetic composite grafts; hereby, we performed a retrospective analysis of long-term follow-up of Bentall procedure using the Valsalva graft and the Perimount Magna Ease prosthesis. METHODS From June 2000 to March 2019, 309 patients received an aortic root and valve replacement with a bioprosthetic composite graft. The mean age was 69 ± 6.9 years, and the majority were men (88%); most of them were affected by aortic stenosis (86%) and the mean aortic root diameter was 48.6 ± 5.5 mm. RESULTS Freedom from cardiac death was 76.8% [confidence interval (CI) 32.5-94.0] at 16 years. Freedom from thromboembolism, haemorrhage, structural valve deterioration and infective endocarditis was 98.2% (CI 96.0-98.9), 95.2% (CI 87.1-98.2), 87.5% (CI 63.2-97.1) and 79.6% (CI 45.3-95.6) at 16 years, respectively. Freedom from reoperation was 74.7% (CI 41.9-90.6). CONCLUSIONS These data indicate that, in experienced centres, the Bentall procedure is a safe and effective intervention. This is the first long-term follow-up that analyses the results after implantation of a composite graft made with the Perimount Magna Ease aortic valve and the Valsalva graft.
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Affiliation(s)
| | | | | | - Giulio Folino
- Department of Cardio-Thoracic and Vascular Sciences, University of Padua, Padova, Italy
| | - Luca Paolo Weltert
- Department of Cardiac Surgery, European Hospital, Rome, Italy.,Department of Biostatistics, San Camillus International University of Health Sciences, Rome, Italy
| | - Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Saverio Nardella
- Department of Cardiac Surgery, Sant'Anna Hospital, Catanzaro, Italy
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De Paulis R, Scaffa R, Weltert L, Salica A. Mimicking mother nature: The Valsalva graft. J Thorac Cardiovasc Surg 2020; 159:1758-1763. [DOI: 10.1016/j.jtcvs.2019.06.128] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/03/2019] [Accepted: 06/08/2019] [Indexed: 11/16/2022]
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Chirichilli I, Irace F, Weltert L, Tsuda K, Scaffa R, Salica A, Galea N, De Paulis R. Morphological modification of the aortic annulus in tricuspid and bicuspid valves after aortic valve reimplantation: an electrocardiography-gated computed tomography study†. Eur J Cardiothorac Surg 2019; 56:778-784. [DOI: 10.1093/ejcts/ezz065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/02/2019] [Accepted: 02/07/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
OBJECTIVES:
Aortic valve-sparing operations have been shown to produce fewer valve-related complications than valve replacement. The aortic root is a morphological and functional unit in which the annulus plays an important role on dynamism, shape and geometry of the valve with different results in bicuspid aortic valves (BAVs) or tricuspid aortic valves (TAVs). The aim is to evaluate the differences in the size and shape of the aortic annulus between native BAVs and TAVs using ECG-gated computed tomography (CT) after a reimplantation procedure.
METHODS:
We selected 35 patients scheduled for aortic valve reimplantation who underwent good-quality preoperative and postoperative ECG-gated contrast-enhanced CT scan of the aortic root. Twenty-three patients had TAV, 8 patients type 1 BAV and 4 patients type 0 BAV. Major diameter and minor diameter, perimeter (P) and area (A) were measured. The shape of the aortic annulus was considered ‘circular’ or ‘elliptic’ according to the Ellipticity Index. We also selected a subgroup of 18 patients (9 TAVs and 9 BAVs) to evaluate annular shape and size variations through the cardiac cycle and to study the expansibility both in the preoperative and in the postoperative phases.
RESULTS:
Preoperative CT scans showed an elliptic shape of TAVs (Ellipticity Index 1.3 ± 0.1), a circular shape of type 0 BAVs (1.1 ± 0.1) and an intermediate behaviour of type 1 BAVs, suggesting a possible gradual spectrum of circularity from TAVs to type 1 BAVs to type 0 BAVs. Postoperative CT scans did not show any significant difference in annular shape among the 3 groups, which demonstated a similar roundness, obviating the preoperative differences. Analysing the expansibility of the aortic annulus during the cardiac cycle, we observed that it was completely absent in the preoperative phase in BAVs, while in the postoperative phase, both TAVs and BAVs showed a small but similar expansibility after the annular reduction.
CONCLUSIONS:
There is a possible gradual spectrum in terms of shape, from native TAVs, to type 1 BAVS to type 0 BAVs. These differences are eliminated in the postoperative phase, suggesting an active role of the annuloplasty on the geometry of the aortic annulus. The preoperative analysis showed a complete inelasticity of BAVs, which was partly restored in the postoperative phase.
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Affiliation(s)
| | - Francesco Irace
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Luca Weltert
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Kazumasa Tsuda
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Andrea Salica
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Nicola Galea
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy
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Weltert L, Guerrieri L, Chirichilli I, D’Aleo S, Salica A, Scaffa R, Bellisario A, De Paulis R. OC26 EXTERNAL STENTING OF VEIN GRAFTS IN OFF PUMP CORONARY BYPASS SURGERY AND SEQUENTIAL GRAFTING. J Cardiovasc Med (Hagerstown) 2018. [DOI: 10.2459/01.jcm.0000549907.80767.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Chirichilli I, Irace F, Weltert L, Tsuda K, Scaffa R, Salica A, Galea N, De Paulis R. OC45 MORPHOLOGICAL MODIFICATION OF THE AORTIC ANNULUS IN TRICUSPID AND BICUSPID VALVES AFTER AORTIC VALVE REIMPLANTATION PROCEDURE. J Cardiovasc Med (Hagerstown) 2018. [DOI: 10.2459/01.jcm.0000549891.25617.f6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Weltert L, D’Aleo S, Salica A, Bellisario A, Scaffa R, Wolf LG, Chirichilli I, De Paulis R. OC13 COMPARING SPRAYABLE HEMOSTAT/SEALANT ADJUNCT TO TRADITIONAL HEMOSTASIS AFTER CARDIAC REDO SURGERY. J Cardiovasc Med (Hagerstown) 2018. [DOI: 10.2459/01.jcm.0000549926.46702.ec] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Weltert L, Chirichilli I, D’Aleo S, Guerrieri L, Salica A, Scaffa R, Ricci A, Bellisario A, De Paulis R. EP01 5-YEARS FOLLOW-UP OF AORTIC PROSTHESIS ENDOCARDITIS TREATED USING BIOINTEGRAL CONDUIT. J Cardiovasc Med (Hagerstown) 2018. [DOI: 10.2459/01.jcm.0000550001.22045.ee] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Weltert L, D’Aleo S, Chirichilli I, Wolf LG, Ricci A, Scaffa R, Salica A, Bellisario A, De Paulis R. RF09 BEST OF BOTH WORLDS. J Cardiovasc Med (Hagerstown) 2018. [DOI: 10.2459/01.jcm.0000550009.04120.ab] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Weltert L, Turani F, Falco M, Scaffa R, Salica A, Bellisario A, Chirichilli I, De Paulis R. OC36 IMPROVEMENT OF HAEMODYNAMIC AND RESPIRATORY PARAMETERS DURING COUPLED PLASMA FILTRATION AND ADSORPTION (CPFA) AND CORRELATION WITH CLEARANCE OF THE INFLAMMATORY MEDIATORS IN SEPTIC PATIENTS. J Cardiovasc Med (Hagerstown) 2018. [DOI: 10.2459/01.jcm.0000549903.27402.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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De Paulis R, Scaffa R, Salica A, Weltert L, Chirichilli I. Biological solutions to aortic root replacement: valve-sparing versus bioprosthetic conduit. J Vis Surg 2018; 4:94. [PMID: 29963383 DOI: 10.21037/jovs.2018.04.12] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/11/2018] [Indexed: 11/06/2022]
Abstract
Composite valve graft implantation described by Bentall and De Bono is a well-documented technique of aortic root replacement used for a large spectrum of pathologic conditions involving the aortic valve and the ascending aorta. While mechanical valves were initially used, biological prostheses were later introduced in order to avoid long-term anticoagulation and its related complications. The increasing age of patients who undergo aortic root surgery, and data supporting the use of a biological aortic valve in the younger population, have significantly increased the need for a composite biological valved conduit. However, parallel to the increased use of biological valve in the context of a Bentall operation, aortic valve-sparing (AVS) operation have also been performed in a growing number of patients. Sarsam and David described the remodeling and the reimplantation procedures more than 25 years ago with the aim of sparing otherwise normal aortic valves in the presence of a root aneurysm. Important achievements in this discipline have occurred over the past decade including development and refinement of valve preserving aortic root replacement techniques, development of a classification system for aortic insufficiency, surgical approaches to cusp disease with different cusp anatomy. Both procedures can now provide excellent root reconstruction and adequate clinical results in terms of late valve durability. The AVS technique offers several advantages over the Bentall procedure, such as no need for oral anticoagulation and lifestyle adjustments. AVS operations have become established alternatives to Bentall procedures for patients with aortic root pathology. However, data comparing the safety and durability of these approaches are lacking.
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Affiliation(s)
| | - Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Andrea Salica
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Luca Weltert
- Department of Cardiac Surgery, European Hospital, Rome, Italy
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De Paulis R, D'Aleo S, Bellisario A, Salica A, Weltert LP, Scaffa R, Wolf LG, Maselli D, Di Mauro M. The fate of small-size pericardial heart valve prostheses in an older patient population. J Thorac Cardiovasc Surg 2017; 153:31-39.e2. [DOI: 10.1016/j.jtcvs.2016.08.063] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 08/26/2016] [Accepted: 08/30/2016] [Indexed: 11/30/2022]
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Salica A, Pisani G, Morbiducci U, Scaffa R, Massai D, Audenino A, Weltert L, Guerrieri Wolf L, De Paulis R. The combined role of sinuses of Valsalva and flow pulsatility improves energy loss of the aortic valve. Eur J Cardiothorac Surg 2015; 49:1222-7. [PMID: 26362428 DOI: 10.1093/ejcts/ezv311] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 07/20/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Normal aortic valve opening and closing movement is a complex mechanism mainly regulated by the blood flow characteristics and the cyclic modifications of the aortic root. Our previous in vitro observations demonstrated that the presence of the Valsalva sinuses, independently from root compliance, is important in reducing systolic pressure drop across the aortic valve. This in vitro study was designed to ascertain if this effect is dependent on the flow characteristics. METHODS Stentless 21, 23 and 25 mm aortic prostheses were sutured inside Dacron graft with and without sinuses. Hydrodynamic performance of the root models was investigated in steady-state (continuous) and unsteady-state (pulsatile) flow regimes. Aortic transvalvular pressure drop and effective orifice area (EOA) were evaluated. RESULTS The continuous flow analysis revealed that no marked differences in pressure drop characterized the two root configurations at flow regimes lower than 15 l/min, independently of valve size. Conversely, at higher flow regimes (up to 30 l/min) a relatively low pressure drop continued to characterize grafts with sinuses, whereas marked increments in pressure drop were measured in straight grafts, especially in the smaller size (77.05 ± 4.58 vs 23.80 ± 2.44 mmHg; 18.40 ± 1.31 vs 7.66 ± 0.37 mmHg and 29.54 ± 0.17 vs 7.12 ± 0.07 mmHg, for 21, 23 and 25 mm valve, respectively). Under pulsatile conditions, the presence of sinuses clearly confirmed lower pressure drops also more evident in the smaller valve sizes (53.89 ± 1.06 vs 11.6 ± 0.24 mmHg at 7 l/min for 21 mm valve). EOA values were always lower in the absence of sinuses. In continuous flow regimes, at 30 l/min EOA of 25 mm valve size was 3.67 ± 0.02 cm(2) in the Valsalva model versus 1.79 ± 0.01 cm(2) for the Straight model. In pulsatile tests, at 7 l/min a 25-valve size demonstrated an EOA of 5.47 ± 0.60 in the Valsalva model versus 2.50 ± 0.02 cm(2) in the Straight model. CONCLUSIONS These findings (i) confirm the hypothesis that the sinuses of Valsalva play a key role in optimizing the aortic haemodynamics during systole, minimizing energy losses; (ii) suggest that the sinuses of Valsalva are needed because of the complex nature of blood flow during ejection.
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Affiliation(s)
- Andrea Salica
- Division of Cardiac Surgery, European Hospital, Rome, Italy
| | - Giuseppe Pisani
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Umberto Morbiducci
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | | | - Diana Massai
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Alberto Audenino
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Luca Weltert
- Division of Cardiac Surgery, European Hospital, Rome, Italy
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De Paulis R, Chirichilli I, Scaffa R, Weltert L, Maselli D, Salica A, Guerrieri Wolf L, Bellisario A, Chiariello L. Long-term results of the valve reimplantation technique using a graft with sinuses. J Thorac Cardiovasc Surg 2015; 151:112-9. [PMID: 26349596 DOI: 10.1016/j.jtcvs.2015.08.026] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/27/2015] [Accepted: 08/08/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Aortic valve reimplantation is the most commonly used technique to spare the aortic valve. Long-term results data are scarce and available only with the use of standard straight graft. We examined the long-term results of reimplantation of the aortic valve using a graft incorporating sinuses of Valsalva. METHODS From May 2000 to December 2014, 124 patients had an aortic valve reimplanted into a graft with sinuses of Valsalva. The mean age was 53 ± 13 years and the majority were men (87%). Marfan syndrome was present in 21 patients (17%) and 12% had a bicuspid valve. Patients were prospectively followed by means of transthoracic echocardiography. The mean follow-up was 63 ± 52 months. RESULTS Overall survival at 5, 10, and 13 years was 94.4% ± 2.2%, 90.5% ± 4.4%, and 81.4% ± 7.3%, respectively. Six patients required reoperation within a time frame of 6 to 96 months. None of the patients died at reoperation. Freedom from reoperation was 95.4% ± 2.3% at 5 years and 90.1% ± 4.3% at 10 and 13 years. All patients who needed reoperation had surgery during the first 5 years. Three patients had residual aortic insufficiency >2. Considering also all patients who underwent reoperation because of aortic insufficiency, freedom from moderate to severe residual aortic insufficiency was 94.1% ± 2.6% at 5 years, and 87.1% ± 4.7% at 10 and 13 years. CONCLUSIONS The majority of patients who had their valve reimplanted in a graft with sinuses continue to perform well after 10 years.
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Affiliation(s)
| | | | | | - Luca Weltert
- Cardiac Surgery Department, European Hospital, Rome, Italy
| | | | - Andrea Salica
- Cardiac Surgery Department, European Hospital, Rome, Italy
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Salica A, Weltert L, Scaffa R, Wolf LG, Nardella S, Bellisario A, De Paulis R. Negative pressure wound treatment improves Acute Physiology and Chronic Health Evaluation II score in mediastinitis allowing a successful elective pectoralis muscle flap closure: Six-year experience of a single protocol. J Thorac Cardiovasc Surg 2014; 148:2397-403. [DOI: 10.1016/j.jtcvs.2014.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 03/31/2014] [Accepted: 04/11/2014] [Indexed: 11/28/2022]
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Guerrieri Wolf L, Scaffa R, Maselli D, Weltert L, Nardella S, Di Roma M, De Paulis R, Tomai F. Intraaortic migration of an epicardial pacing wire: percutaneous extraction. Ann Thorac Surg 2013; 96:e7-8. [PMID: 23816116 DOI: 10.1016/j.athoracsur.2012.12.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 12/05/2012] [Accepted: 12/31/2012] [Indexed: 11/18/2022]
Abstract
Infrequent but serious complications have been described in association with temporary epicardial pacing wires. We describe the case of an intraaortic migration of an infected retained atrial temporary epicardial pacing wire and the transfemoral percutaneous interventional approach for its extraction.
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Maselli D, Scaffa R. [Treatment of infective endocarditis. Early surgery is mandatory in most cases]. G Ital Cardiol (Rome) 2013; 14:471-3. [PMID: 23748545 DOI: 10.1714/1280.14162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Weltert L, de Tullio MD, Afferrante L, Salica A, Scaffa R, Maselli D, Verzicco R, De Paulis R. Annular dilatation and loss of sino-tubular junction in aneurysmatic aorta: implications on leaflet quality at the time of surgery. A finite element study. Interact Cardiovasc Thorac Surg 2013; 17:8-12. [PMID: 23536020 DOI: 10.1093/icvts/ivt116] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES In the belief that stress is the main determinant of leaflet quality deterioration, we sought to evaluate the effect of annular and/or sino-tubular junction dilatation on leaflet stress. A finite element computer-assisted stress analysis was used to model four different anatomic conditions and analyse the consequent stress pattern on the aortic valve. METHODS Theoretical models of four aortic root configurations (normal, with dilated annulus, with loss of sino-tubular junction and with both dilatation simultaneously) were created with computer-aided design technique. The pattern of stress and strain was then analysed by means of finite elements analysis, when a uniform pressure of 100 mmHg was applied to the model. Analysis produced von Mises charts (colour-coded, computational, three-dimensional stress-pattern graphics) and bidimensional plots of compared stress on arc-linear line, which allowed direct comparison of stress in the four different conditions. RESULTS Stresses both on the free margin and on the 'belly' of the leaflet rose from 0.28 MPa (normal conditions) to 0.32 MPa (+14%) in case of isolated dilatation of the sino-tubular junction, while increased to 0.42 MPa (+67%) in case of isolated annular dilatation, with no substantial difference whether sino-tubular junction dilatation was present or not. CONCLUSIONS Annular dilatation is the key element determining an increased stress on aortic leaflets independently from an associated sino-tubular junction dilatation. The presence of annular dilatation associated with root aneurysm greatly decreases the chance of performing a valve sparing procedure without the need for additional manoeuvres on leaflet tissue. This information may lead to a refinement in the optimal surgical strategy.
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Affiliation(s)
- Luca Weltert
- Department of Cardiac Surgery, European Hospital, Rome, Italy.
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Maselli D, Weltert L, Scaffa R, Nardella S, Guerrieri Wolf L, De Paulis R. Differences in aortic cusp coaptation between the reimplantation and the remodeling techniques of aortic valve-sparing surgery: an in vitro porcine model study. J Thorac Cardiovasc Surg 2013; 147:615-8. [PMID: 23395101 DOI: 10.1016/j.jtcvs.2013.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 12/01/2012] [Accepted: 01/14/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We sought to evaluate the effects of the reimplantation type versus the remodeling type of aortic valve-sparing technique on the geometry of the same aortic root. METHODS Fifteen fresh isolated porcine hearts with normal aortic valves and a standard aortoventricular junction size of 23 mm were processed. An aortic valve-sparing replacement was performed by reimplanting the native aortic root inside a 28-mm Valsalva graft (Vascutek Ltd, Renfrewshire, UK). Hearts were subsequently implanted with instruments in a test circuit, and the aortic roots were pressurized at a fixed pressure of 100 mm Hg. Diameters of the aortoventricular junction, of the sinuses, and of the sinotubular junction, as well as effective height and coaptation height of aortic valve leaflets, were measured by echography. Transition from the reimplantation to the remodeling configuration was then achieved by longitudinally cutting the skirt of the graft from the annulus to the top of each commissure. The same measurements were then repeated. RESULTS After transition from the reimplantation to the remodeling configuration, significant increases in the sizes of the aortoventricular junction and of the sinuses were observed. Effective height and coaptation height significantly decreased, and the rounded cross-sectional profile of the aortic valve leaflets flattened. CONCLUSIONS In the same aortic root, transition from the reimplantation to the remodeling configuration of aortic valve-sparing surgery results in a significant increase in aortic root sizes and in a significant reduction of effective height and coaptation height, suggesting a less satisfactory result.
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Affiliation(s)
- Daniele Maselli
- Department of Cardiac Surgery, European Hospital, Rome, Italy.
| | - Luca Weltert
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | - Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy
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Maselli D, Weltert L, Scaffa R, De Paulis R. How to achieve an aortic root remodelling by performing an aortic root reimplantation. Eur J Cardiothorac Surg 2012; 42:e136-7. [DOI: 10.1093/ejcts/ezs447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pisani G, Scaffa R, Ieropoli O, Dell'Amico EM, Maselli D, Morbiducci U, De Paulis R. Role of the sinuses of Valsalva on the opening of the aortic valve. J Thorac Cardiovasc Surg 2012; 145:999-1003. [PMID: 22503205 DOI: 10.1016/j.jtcvs.2012.03.060] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 02/05/2012] [Accepted: 03/20/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The present in vitro study was designed to ascertain whether the presence of sinuses of Valsalva in the aortic root were able to regulate the valve effective orifice area and modulate the gradient across the valve independently from root compliance. METHODS Four different root configurations were prepared. Of the 4, 2 were silicon configurations with the same compliance, 1 with and 1 without sinuses of Valsalva, in which a 25-mm Solo stentless aortic valve was sutured inside. The other 2 configurations were obtained by substituting the upper part of the root with a straight Dacron graft or with a Valsalva graft in a remodeling fashion to reproduce the surgical situation. All roots were mounted in a pulse duplicator to measure the pressure decrease across the valve and effective orifice area at different cardiac outputs. RESULTS With increasing cardiac output up to 7 L/min, an increase in the pressure decrease across the valve was evident in both configurations without sinuses of Valsalva (7.90 ± 1.7 and 11 mm Hg ± 0.1 mm Hg, respectively) but not in those with sinuses (2.87 ± 0.5 and 2.42 mm Hg ± 0.5 mm Hg). Similarly, with increasing cardiac output, the effective orifice area increased significantly only in the roots with sinuses (5.13 ± 0.5 and 5.47 ± 0.5 vs 3.06 ± 0.3 and 2.50 cm(2) ± 0.02 cm(2), respectively). CONCLUSIONS When the cardiac output is increased to greater than the resting physiologic values, the presence of sinuses of Valsalva, independently of root compliance, prevents an increase in the pressure decrease across the valve by way of an increase of the effective orifice area.
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Affiliation(s)
- Giuseppe Pisani
- Department of Mechanics, Politecnico di Torino, Turin, Italy
| | - Raffaele Scaffa
- Department of Cardiac Surgery, European Hospital, Rome, Italy
| | | | | | - Daniele Maselli
- Department of Cardiac Surgery, European Hospital, Rome, Italy
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Scaffa R, Spaziani C, Leporace M, Leonetti S, Di Roma M, Gaspardone A, De Paulis R. Voluminous Atrial Septal Aneurysm May Mask a Large Double Atrial Septal Defect. Ann Thorac Surg 2012; 93:e41. [DOI: 10.1016/j.athoracsur.2011.10.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 10/03/2011] [Accepted: 10/10/2011] [Indexed: 11/30/2022]
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Weltert L, Nardella S, Girola F, Scaffa R, Bellisario A, Maselli D, De Paulis R. Diastolic properties of the Sorin Solo, ATS 3F, Edwards Prima Plus and Medtronic Freestyle stentless valves: an independent in-vitro comparison. J Heart Valve Dis 2012; 21:99-105. [PMID: 22474749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Currently, little is known of the diastolic properties of stentless valves that affect stress and strain on leaflets and, hence, their durability. In a pressurized aortic root model, a series of in-vitro tests was conducted to determine how stentless valves behave in diastole, and how they adapt to different annulus-to-sinotubular junction (STJ) ratios. METHODS Sixteen 25 mm stentless aortic valves (four each of the Sorin Solo, ATS 3F, Edwards Prima Plus and Medtronic FreeStyle) were sutured into a 32 mm Valsalva graft, suspending the commissures into the expandable region (42 mm). The neoaortic root was pressurized and the size of the STJ progressively reduced by wrapping the neocommissural ridge with Dacron rings. Endoscopic views and ultrasound imaging were used to observe the geometry of the leaflets, regurgitation, and the height and level of leaflet coaptation at different annulus-to-STJ ratios. RESULTS Pericardial prostheses built to mimic a cylinder (ATS 3F and Sorin Solo) showed the greatest tolerance to STJ dilatation and a larger coaptation surface, but also a tendency to roll in on themselves in an italic S-shape if oversized. Valves built to mimic native aortic leaflets (porcine Prima Plus and Medtronic Freestyle) showed a reduced tolerance to STJ dilatation, resulting in regurgitation and a smaller coaptation surface, but also a reduced tendency to roll if oversized. CONCLUSION Despite similar systolic performances, stentless prostheses behave differently during diastole. The 3F and Solo valves benefit from a better tolerance to STJ dilatation, while the Prima Plus and Freestyle benefit from a more stable shape of closure under conditions of oversizing.
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Affiliation(s)
- Luca Weltert
- Cardiac Surgery Department, European Hospital, Rome, Italy.
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Maselli D, Ficarra E, Weltert L, Barberi F, Scaffa R, Bellisario A, De Paulis R. A method to avoid knot-tying in artificial chordae implantation for mitral valve repair. J Heart Valve Dis 2010; 19:249-253. [PMID: 20369512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Expanded polytetrafluoroethylene (ePTFE) neo-chordae implantation requires knot-tying inside the heart, which can be especially difficult if a minimally invasive approach is used. A system has been developed that allows the implantation of neo-chordae, without a need for knot-tying, in addition to a simultaneous and reversible length adjustment after the evaluation of valve continence using hydrostatic tests. METHODS The system consists of a suture with a needle at one end and a 20 mm pledgeted loop at the opposite end. The suture presents five stop-knots at constant (2 mm) intervals, starting 35 mm from the base of the loop. The suture is passed first through the leaflet, then through the papillary muscle, then inside a reversible noose-lace (cow-hitch) that is made on the loop. The noose-lace is closed under one of the knots of the suture coming from the papillary muscle. After closing the loop at a presumably optimal length, a hydrostatic test is performed. The chordal length can be modified by releasing the noose-lace and sliding it over another fixing-knot until an optimal distance is obtained. RESULTS Fourteen patients underwent repair with this technique. No deaths or major adverse events occurred. All patients underwent echocardiography at discharge, and again at six and 12 months after surgery. Thirteen patients had no residual insufficiency, and one patient had mild postoperative insufficiency but without progression of regurgitation at the sixth postoperative month. CONCLUSION This new technique facilitates artificial chordae implantation. The short-term results are satisfactory, but further follow up is required.
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Affiliation(s)
- Daniele Maselli
- Department of Cardiac Surgery, European Hospital, Rome, Italy
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De Paulis R, Maselli D, Scaffa R, Nardella S. Double-arterial cannulation for aortic valve replacement with porcelain aorta. Eur J Cardiothorac Surg 2009; 36:769-70. [PMID: 19616443 DOI: 10.1016/j.ejcts.2009.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Revised: 06/06/2009] [Accepted: 06/10/2009] [Indexed: 11/25/2022] Open
Abstract
We describe a new technique of aortic valve replacement (AVR) in patients with porcelain aorta. Three patients (mean age 75 years) were treated. The cardiopulmonary bypass (CPB) was established after side-graft right axillary artery and direct femoral artery cannulation. Venous drainage was obtained by atrio-caval cannulation. The procedures were performed in mild hypothermia (30 degrees C). Cerebral perfusion was carried out by clamping the innominate artery and all epiaortic vessels. The aorta was endoclamped by a Foley balloon inserted into the isthmus. The aorta was then opened longitudinally for 10 cm to expose and replace the aortic valve. Near-infra-red spectroscopy (NIRS) and bilateral radial artery pressure were used to monitor effective cerebral perfusion. Operative mortality was absent. The mean time of CPB was 73 min. NIRS-derived tissue oxygenation was maintained above 55%. Postoperative course was uneventful. This technique has several advantages: first, the cannulation of right axillary and the common femoral artery allows simultaneous cerebral and systemic perfusion. Second, any form of cross-clamp is avoided and the aorta is occluded away from the epiaortic vessels. Third, there is an increased freedom to choose the best place for aortotomy.
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Affiliation(s)
- Ruggero De Paulis
- Division of Cardiac Surgery, European Hospital, via Portuense, 700, 00149 Rome, Italy.
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Weltert L, De Paulis R, Scaffa R, Maselli D, Bellisario A, D'Alessandro S. Re-creation of a sinuslike graft expansion in Bentall procedure reduces stress at the coronary button anastomoses: A finite element study. J Thorac Cardiovasc Surg 2009; 137:1082-7. [PMID: 19379971 DOI: 10.1016/j.jtcvs.2008.10.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2008] [Revised: 08/24/2008] [Accepted: 10/10/2008] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The Bentall procedure is routinely performed using a straight Dacron graft coupled with a mechanical or a biologic valve. Creation of coronary ostia buttons significantly reduces tension on the coronary anastomoses and consequently the incidence of pseudoaneurysm formation. We sought to evaluate if the use of a specifically designed graft with a sinuslike root portion that bulges out upon pressurization can reduce stress on coronary anastomoses. A finite element computer-assisted stress analysis was used to simulate these 2 different anatomic conditions and to analyze tension in computed tomographic scans obtained from patients operated on with either a straight or a "sinus" graft. METHODS Theoretical models of the procedures with finite element computer-aided design technique were created and tested with the Abaqus Standard Suite, verifying the pattern of stress and strain when a uniform pressure of 200 mm Hg was applied to the model. Next, using SimpleWare SCanIP technology, computed tomographic scans of patients having both procedures were used to obtain finite element mesh models. A uniform pressure of 200 mm Hg was then applied, and the distribution of stress and strain was analyzed. RESULTS Von Mises Charts are color-coded, computational, 3-dimensional stress-pattern graphics that show that stress around the coronary ostia in a standard straight graft model is nearly double compared with the model with sinuses (peak stress of 0.4 Mpa for the sinus model and 0.7 Mpa for the traditional straight model). In computed tomographic scan reconstructions, the stress contour is uniformly distributed in the graft with sinuses, and it is highly concentrated around the ostia in the straight graft. Accordingly, higher-peak stress values are registered in the straight configuration (1.8 MPa for the sinus graft and 2.5 MPa for standard graft). CONCLUSION Even though finite elements technique is necessarily a simplification of a real biologic environment, all tests seem to indicate that a standard tubular graft gives a higher stress to coronary sutures. Relieving the stress on the coronary anastomoses by using a graft with preformed sinuses of Valsalva may decrease the incidence of postoperative complications such as bleeding and late pseudoaneurysm formation.
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Affiliation(s)
- Luca Weltert
- Cardiac Surgery Department, European Hospital, Rome, Italy
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Weltert L, De Paulis R, Maselli D, Scaffa R. Sorin Solo stentless valve: extended adaptability for sinotubular junction mismatch. Interact Cardiovasc Thorac Surg 2008; 7:548-51. [PMID: 18487239 DOI: 10.1510/icvts.2008.176941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Stentless valve continence is affected by the implantation technique, annular symmetry and dilatation of the sinotubular junction. We tested in vitro how the Sorin Solo stentless pericardial valve adapts to a slightly dilated sinotubular junction. Stentless Sorin Solo aortic valves (25 mm) were sutured into a 32-mm Valsalva graft suspending the commissures into the expandable region of the graft. The neo-aortic root was pressurized and sinotubular junction size progressively decreased by wrapping the neocommissural ridge with Dacron rings. Direct endoscopic view and ultrasound imaging were used to observe geometry and morphology of leaflets, regurgitation, height and level of leaflets coaptation. Fresh porcine valves of the same annular size were used as controls. Solo valves had mild regurgitation at baseline, became continent at 32 mm sinotubular junction size and remained continent at any size of reduction, with optimal coaptation height and level. Porcine valves had severe regurgitation at baseline, became continent at 30 mm and showed mild insufficiency and reduction of the coaptation level at a sinotubular junction of 28 mm. The Solo valve prevents residual valve regurgitation for a wider range of sinotubular junction mismatch when compared with natural porcine valves. This extended tolerance to sinotubular junction mismatch suggests a safe use of stentless valves even in suboptimal geometry roots.
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Affiliation(s)
- Luca Weltert
- Department of Cardiac Surgery, European Hospital, Via Portuense 700, 00149 Rome, Italy
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De Paulis R, Salica A, Maselli D, Scaffa R, Bellisario A, Weltert L. Initial experience of an arterial shunt for bilateral antegrade cerebral perfusion during hypothermic circulatory arrest. Ann Thorac Surg 2008; 85:624-7. [PMID: 18222278 DOI: 10.1016/j.athoracsur.2007.06.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Revised: 06/12/2007] [Accepted: 06/13/2007] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study is to describe an intravessel cerebral shunt that allows perfusion of both cerebral hemispheres through the axillary artery. DESCRIPTION The cerebral shunt is a 10-cm to 12-cm long cannula with a lumen for blood perfusion and two balloons, one at each distal end. The proximal balloon is adapted for retaining the proximal end of the catheter in the innominate artery; the second inflatable balloon is adapted for retaining the distal end of the catheter into the left common carotid artery. EVALUATION Three consecutive patients received bilateral brain perfusion through the right axillary artery with the use of this cerebral shunt. CONCLUSIONS The cerebral shunt allowed bilateral cerebral perfusion as verified with cerebral oximetry in the absence of any evident neurologic dysfunction.
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De Paulis R, Scaffa R, Maselli D, Weltert L, Salica A, Bellisario A. Valsalva graft in the Bentall procedure: from mechanical valve to the BioValsalva, world's first biological aortic conduit. Surg Technol Int 2008; 17:216-221. [PMID: 18802905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Aortic root replacement is the procedure of choice for patients with ascending aortic aneurysms and diseased aortic valve leaflets. The increasing age of patients who undergo aortic root surgery, and data that support the use of a biological aortic valve in the younger population, have significantly increased the need for a composite biological valved conduit. The third-generation Triplextrade (Terumo Vascutek, Renfrewshire, Scotland, UK) Dacron conduit with its three-layer technology, can be stored in glutaraldehyde along with biological prostheses while maintaining a complete blood impermeability. As the result of this fundamental improvement, the ready-to-use composite biological valved graft is currently available for the first time in different sizes, which avoids the need of assembling it on the surgical table. The procedure is expedited and a better hemostasis achieved because of the intrinsic characteristics of the new three-layered conduit. The BioValsalva (Terumo Vascutek, Renfrewshire, Scotland, UK) has been obtained by suturing a stentless aortic valve (Elan, Kohler, Leeds, UK) inside a Triplex Valsalva graft and combining the advantages of a biological valved conduit with the advantages of better leaflets dynamics, less tension on coronary ostia, and improved coronary flow proper of the Valsalva conduit. The authors' preliminary clinical experience with the BioValsalva is reported herein and the technique is discussed.
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Maselli D, De Paulis R, Scaffa R, Weltert L, Bellisario A, Salica A, Ricci A. Sinotubular Junction Size Affects Aortic Root Geometry and Aortic Valve Function in the Aortic Valve Reimplantation Procedure: An In Vitro Study Using the Valsalva Graft. Ann Thorac Surg 2007; 84:1214-8. [PMID: 17888972 DOI: 10.1016/j.athoracsur.2007.05.035] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Revised: 05/09/2007] [Accepted: 05/11/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sinotubular junction (STJ) size in aortic valve reimplantation procedures is usually predetermined on the basis of experience or intraoperative mathematical calculations. Given the small coaptation reserve of aortic valve leaflets, small errors can produce an incompetent aortic valve. We tested in vitro the effect of geometrically changing the relationship between aortic annulus size and STJ size on aortic root geometry and aortic valve function. METHODS Twenty-five-millimeter diameter scalloped porcine aortic roots were reimplanted into 32-mm Valsalva grafts (Vascutek, Renfrewshire, Scotland), suspending commissures into the expandable region of the graft itself. Neoaortic roots were pressurized up to 100 mm Hg. Sinotubular junction size was then changed by wrapping the neocommissural ridge with Dacron rings of decreasing size. Geometry of the aortic root, anatomy of aortic valve leaflets, and extent of their coaptation were analyzed by direct endoscopic view and by ultrasound imaging techniques. RESULTS Pressurizing unwrapped aortic root resulted in centrifugal displacement of commissures, aortic leaflets tethering and bending, and central aortic regurgitation. By reducing STJ size, coaptation height of aortic valve leaflets first increased to reach a maximum for an STJ size corresponding to 30 mm, and then decreased for further reduction of STJ size. Excess reduction of STJ size also resulted in prolapsed aortic leaflets and eccentric aortic regurgitation. CONCLUSIONS In the reimplantation procedure performed with a Valsalva graft, aortic valve function and leaflet coaptation can be optimized by optimizing STJ size.
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Affiliation(s)
- Daniele Maselli
- Department of Cardiac Surgery, European Hospital, Rome, Italy.
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Maselli D, De Paulis R, Weltert L, Salica A, Scaffa R, Bellisario A, Mingiano A, Celi S, Di Puccio F. A new method for artificial chordae length “tuning” in mitral valve repair: Preliminary experience. J Thorac Cardiovasc Surg 2007; 134:454-9. [PMID: 17662789 DOI: 10.1016/j.jtcvs.2007.04.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Revised: 03/15/2007] [Accepted: 04/11/2007] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Implanting expanded polytetrafluoroethylene neochordae is an established technique in treating complex mitral regurgitation. Difficulty in obtaining reliable preoperative and intraoperative measurements of an ideal neochordae length, as well as the unfeasibility of adjusting lengths once set in place with traditional techniques, led us to develop a system that allows rapid change of length after the evaluation of valve continence with hydrostatic tests. METHODS The system consists of two components: a papillary component with arrest knots at constant intervals and a leaflet component with a reversible noose-lace to fix the loop to 1 of the knots on the papillary component. After implantation and coupling of the two components at a presumable optimal length, a prosthetic ring is sutured in place. Hydrostatic testing is then performed. Optimal chordae length can be obtained by releasing the noose-lace and sliding it over another fixing-knot. The adjustment can be performed as often as required without placing stress on the anatomic structures. RESULTS Twenty patients underwent repair with this technique. No deaths or major adverse events occurred. All patients underwent echocardiography, both at discharge and 6 months after the operation. A total of 14 patients had no residual insufficiency, 5 patients had mild or trivial postoperative insufficiency without progression of regurgitation at the sixth month, and only 1 patient had mild insufficiency at discharge progressing to moderate insufficiency at the sixth month. CONCLUSION This new technique facilitates an otherwise complicated procedure. Short-term results are satisfactory, but further follow-up is required.
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Affiliation(s)
- Daniele Maselli
- Department of Cardiac Surgery, European Hospital, Rome, Italy.
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De Paulis R, Schmitz C, Scaffa R, Nardi P, Chiariello L, Reul H. In vitro evaluation of aortic valve prosthesis in a novel valved conduit with pseudosinuses of Valsalva. J Thorac Cardiovasc Surg 2005; 130:1016-21. [PMID: 16214513 DOI: 10.1016/j.jtcvs.2005.04.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2004] [Revised: 04/14/2005] [Accepted: 04/22/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study was undertaken to determine whether the presence of vortices immediately above a prosthetic aortic valve could negatively influence the in vitro hydrodynamic performances of a biologic or mechanical valve implanted in a new Dacron polyester fabric conduit that incorporates sculpted sinuses of Valsalva. METHODS With a computer-controlled pulse duplicator, the in vitro performance (pressure differences, closure and leakage volumes, and energy losses) of a 25-mm mechanical or biologic prosthesis implanted in a standard Dacron straight conduit or in the new Dacron graft with a sculpted sinus were analyzed and compared. RESULTS The mechanical and biologic prostheses at 7 L/min cardiac output showed pressure drops across the valve of 8.72 mm Hg and 13.45 mm Hg, respectively, when inserted in the new Valsalva-style graft and of 7.97 mm Hg and 12.94 mm Hg, respectively, when inserted in the standard graft. The closure and leakage volumes for mechanical valves were higher than those for biologic valves; however, the presence or absence of sinuses did not result in significant differences in closure and leakage volumes. The maximal total energy losses were 5.89% and 9.49% for mechanical and biologic valves, respectively. No differences were evident between the two different Dacron grafts for each prosthetic heart valve. CONCLUSION The normal opening and closing behavior of a prosthetic aortic valve was not altered or modified by a different root shape above the heart valve. The presence of vortices inside the pseudosinuses of Valsalva did not influence the hydrodynamic properties of the biologic and mechanical valves tested.
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De Paulis R, de Notaris S, Scaffa R, Nardella S, Zeitani J, Del Giudice C, De Peppo AP, Tomai F, Chiariello L. The effect of bilateral internal thoracic artery harvesting on superficial and deep sternal infection: The role of skeletonization. J Thorac Cardiovasc Surg 2005; 129:536-43. [PMID: 15746736 DOI: 10.1016/j.jtcvs.2004.07.059] [Citation(s) in RCA: 149] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the relative risk of sternal dehiscence in patients undergoing bilateral internal thoracic artery harvesting and to assess whether and to what extent the technique of artery skeletonization might reduce this risk. METHODS Prospectively collected data on patients undergoing coronary artery bypass operations with at least a single internal thoracic artery were reviewed. The last 450 patients receiving bilateral internal thoracic artery grafts were compared with 450 patients who received a single internal thoracic artery during the same period. The left internal thoracic artery was always harvested in a pedicled fashion. Among patients receiving a bilateral internal thoracic artery, both arteries were harvested in a pedicled fashion in 300 cases, whereas both internal thoracic arteries were skeletonized in the remaining 150 cases. RESULTS Compared with a single internal thoracic artery, harvesting both internal thoracic arteries either in a skeletonized or in a pedicled fashion increased the chance of deep (1.1% vs 3.3% vs 4.7%; P = .01) or superficial (4.8% vs 7.8% vs 12%; P = .002) sternal infection. However, the technique of artery harvesting (odds ratio, 4.1; 95% confidence interval, 1.4-12.1); the presence of peripheral arteriopathy (odds ratio, 3.1; 95% confidence interval, 1.2-8.5), and resternotomy for bleeding (odds ratio, 8.2; 95% confidence interval, 2.0-33.6) were the only independent predictors for deep sternal infection, whereas the technique of artery harvesting (odds ratio, 3.0; 95% confidence interval, 1.6-5.4), female sex (odds ratio, 2.2; 95% confidence interval, 1.2-4.2), and diabetes (odds ratio, 1.7; 95% confidence interval, 1.0-2.9) were the only independent predictors of superficial sternal infection. In diabetic patients, there was no difference in the incidence of deep sternal infection among patients receiving a single internal thoracic artery or double skeletonized internal thoracic arteries ( P = .4). CONCLUSIONS Bilateral internal thoracic artery harvesting carries a higher risk of sternal infection than harvesting a single internal thoracic artery. Skeletonization of both internal thoracic arteries significantly decreases this risk. A strategy of bilateral thoracic artery grafting can also be offered to patients at high risk for wound infection.
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