The Valsalva graft in aortic valve repair and replacement

Virtual Reality Computed Tomography Evaluation - Anatomy and Clinical Implications for Valve-Sparing Aortic Root Replacement

BACKGROUND

Three-dimensional aortic root evaluation using virtual reality (VR) techniques for valve-sparing aortic root replacement (VSARR) preparation has not yet been implemented, so we demonstrated VR computed tomography (VR-CT) and assessed its utility for VSARR.

METHODS AND RESULTS

We enrolled 72 patients who underwent multidetector CT before elective VSARR for annuloaortic ectasia with tricuspid aortic valve. The geometries of their aortic roots were measured with a VR-CT workstation. The mean values of geometric height (GH), free margin length (FML), and commissural height (CH) were 17.2±2.4 mm, 36.0±5.2 mm, and 24.0±4.3 mm, respectively. The right coronary/noncoronary CH was significantly greater than the left coronary/right coronary and left coronary/noncoronary CH. The left coronary cusp had the shortest FML, intercommissural distances (ICD), and smallest central angle. Although the right coronary cusp had the largest values for FML, ICD, and central angle, the right coronary cusp had the lowest GH and EH. The VR-CT measurements strongly correlated with intraoperative alternatives, especially with mean GH (R2=0.75) and left coronary/noncoronary CH (R2=0.79). Furthermore, mean GH was observed to be significantly different among the selected graft size groups; therefore, the preoperative mean GH could play a significant role in graft sizing.

CONCLUSIONS

VR-CT evaluation allows a thorough understanding of aortic root anatomy, which could facilitate VSAAR.

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.