A refined flanged Bentall technique using Valsalva tube graft for proximal reinforcement

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

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