Aortic Root Remodeling With Modified Sleeve Procedure

Introduction
Valve sparing operations provide excellent long term results but are technically demanding and time consuming (1,2). An alternative approach is the “sleeve” technique (3).

Since 2006 we have addressed aortic root disease with a modified sleeve procedure, and have performed 180 interventions in such a way (3,4).

Patient selection
The procedure addresses aortic root ectasia or aneurysm with or without aortic regurgitation. The selection criteria are aortic root diameter ≥ 50 mm, or ≥ 45 if associated with an ascending aorta aneurysm, with or without aortic regurgitation. Bicuspid patients are suitable. Coronary anomalies like an intramural course, separated ostia of the anterior descending and circumflex artery, and short left main trunk are drawbacks.

Operative steps
- The aorta is cross clamped and transected 1 cm above the STJ
- Referral stitches are placed above each commissure. The valve is inspected and the VAJ is measured.
- Coronary ostia are identified.
- The aortic root is dissected underneath the VAJ.
- Coronary stems are mobilized.
- A Valsalva shaped conduit is prepared by trimming the proximal collar in three small crescent shapes and making two keyholes of approximately 1 cm in diameter surrounded by 2 mm radial incisions.
- The graft is secured at the level of the VAJ by means of three U-shaped 4/0 prolene stitches reinforced with pericardium pledgets.
- Another stitch is placed at the vertical slit of each keyhole underneath each button.
- The cusps are then suspended by means of three single U stitches placed just above each commissure and trough the graft at the STJ level.
- The STJ is secured to the graft by a running suture.
- The distal anastomosis is performed.

Preference card:
A Dacron graft with pseudosinuses is required.

Tips and pitfalls:
Thorough dissection of the aortic root until the VAJ is mandatory, as well as mobilization of the coronary stems.
Sizing of the graft is crucial. The choice is between 28, 30 and 32 mm according to VAJ diameter, degree of aortic regurgitation, dimensions of the Valsalva sinuses, diameter of the STJ and patient size. We consider the VAJ to be dilated when bigger than 28 mm. The aim is to restore the normal aortic root unit anatomy preserving its dynamics and leaflet kinematics (5).

In case of eccentric origin of a coronary button the inferior opening of the keyhole should be done in the middle of the corresponding sinus, the vertical incision must be carried straight, then the slot for the coronary button should be displaced leftward or rightward according to the anatomical pattern.

The radial incisions of the keyholes are made to avoid coronary stems constriction.

The stitch placed at the vertical slit of each keyhole is necessary to constrain and stabilize the VAJ and to avoid excessive bulging of the Valsalva sinuses.

The STJ must be secured at the same level of the graft STJ. Care should be taken to properly distribute the excess of native aortic tissue in order to achieve a secure haemostasis, bleeding could be troublesome.

Reference(s)

1) Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A,Radley-Smith R. Late results of a valve-preserving operationin patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg 1998;115:1080–90.
2) David TE, Feindel CM, Webb GD, Colman JM, Armstrong S, Maganti M. Long-term results of aortic valve-sparing operations for aortic root aneurysm. J Thorac Cardiovasc Surg 2006;132:347–54.
3) Hess PJ, Klodell CT, Beaver TM, Martin TD. The Florida sleeve: a new technique for aortic root remodeling with preservation of the aortic valve and sinuses. Ann Thorac Surg 2005;80:748–50.
4) Gamba A, Tasca G, Giannico F, Lobiati E, Skouse D, Galanti A, Martino AS, Triggiani M. Early and medium term results of the sleeve valve-sparing procedure for aortic root ectasia. Ann Thorac Surg. 2015;99(4):1228-33. doi: 10.1016/j.athoracsur.2014.10.044.
5) Tasca G, Selmi M, Riva B, Lobiati E, Gamba A, Redaelli A, Votta E. Aortic root dynamics in sleeve aortic sparing procedure: echocardiographic and computational studies. Semin Thorac Cardiovasc Surg. 2020;32(4):635-643. doi: 10.1053/j.semtcvs.2019.07.010.