The Florida Sleeve: A New Technique for Aortic Root Remodeling With Preservation of the Aortic Valve and Sinuses

doi:10.1016/j.athoracsur.2004.02.092

The Annals of Thoracic Surgery

Volume 80, Issue 2, August 2005, Pages 748-750

https://doi.org/10.1016/j.athoracsur.2004.02.092 Get rights and content

Aortic valve salvage remains the procedure of choice for patients with incompetent valves and normal leaflet morphology. Here my colleagues and I describe a new technique for aortic root remodeling with preservation of the aortic valve.

Section snippets

Technique

Pre-cardiopulmonary bypass TEE assessment of the aortic root is used to evaluate leaflet morphology, the degree of valve prolapse (if any), and annular and sinotubular dimensions. Under cardioplegic arrest, the ascending aorta is transected just above the sinotubular junction, and the aortic root is completely mobilized circumferentially down to the aortic annular level, including mobilization of the proximal portions of the coronary arteries. Exposure under the coronary arteries down to the

Results

There were 2 in-hospital deaths. One patient died after a stroke, and another died from multiorgan system dysfunction and sepsis. One patient required delayed sternal closure after severe coagulopathy. She was the only patient to return to the operating room for any reason in the postoperative period. There were no perioperative myocardial events. All patients had intraoperative TEE evaluation of the aortic valve before leaving the operating room. No patient had more than trace aortic

Comment

Valve-sparing aortic root replacement, pioneered by Yacoub, David, and Feindel [4, 5], has proven to be safe and effective. Multiple recent reports have documented an increasing number of centers that use these techniques, along with increasing indications for their use [6]. However, the total number of these procedures performed yearly is still quite small, because most surgeons have been reluctant to implement them. The paucity of data on the longevity of the repairs has served to further

References (6)

T.E. David et al.
Results of aortic valve-sparing operations
J Thorac Cardiovasc Surg
(2001)
D.C. Miller
Valve-sparing aortic root replacement in patients with the Marfan syndrome
J Thorac Cardiovasc Surg
(2003)
K.S. Kunzelman et al.
Aortic root and valve relationshipsimpact on surgical repair
J Thorac Cardiovasc Surg
(1994)

There are more references available in the full text version of this article.

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Valve-sparing root replacement is an attractive alternative to composite mechanical or biologic prostheses for aortic root aneurysms in children. Data on outcomes in pediatric patients are limited. We present our institutional experience with 100 consecutive pediatric valve-sparing aortic root procedures.
All children who underwent valve-sparing root replacement at our institution from May 1997 to August 2017 were identified, and echocardiographic and clinical data were reviewed. The primary end point was mortality, and secondary end points included complications, further interventions, and subsequent valvular dysfunction.
Median age at operation was 13.6 years (interquartile range, 9.42-15.9); 51 patients (51%) had Marfan syndrome, and 39 patients (39%) had Loeys–Dietz syndrome. Mean preoperative maximum sinus diameter was 4.4 ± 0.71 cm (z score 7.3 [5.7-9.3]). Most patients (n = 80, 80%) underwent reimplantation procedures with a Valsalva graft. Four patients (4%) underwent David I reimplantation with a straight-tube graft, 13 patients (13%) underwent a Yacoub remodeling procedure, and 3 patients (3%) underwent a Florida sleeve procedure. Perioperative valve-sparing root replacement mortality was 2% (n = 2). Six patients required late reintervention for development of pseudoaneurysms. Eight patients underwent additional aortic surgery. Average time to reoperation was 7.23 ± 4.56 years. Of the 84 patients undergoing a reimplantation procedure, 5 (5.9%) underwent late valve replacement versus 5 (33.3%) of the 15 patients who received a remodeling procedure (P = .001).
Valve-sparing root replacement is a safe and effective option for children with aortic root aneurysms in children. The reimplantation procedure is preferred. Late aortic insufficiency and pseudoaneurysm formation remain late concerns.
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Citation Excerpt :
However, with careful selection, some younger patients with aortic dissections can undergo valve sparing aortic root repair as an alternative to full root replacement and avoid life-long anticoagulation with a mechanical valve.8 The Florida sleeve is a unique aortic root remodeling technique as it not only preserves the aortic valve leaflets, but also the sinuses and commissural alignments as well, while at the same time narrowing the aortic annulus and sinotubular junction.9,10 Preserving the aortic valve circumvents the need for either bioprosthetic valves prone to future intervention or mechanical valves with their attendant anticoagulation and bleeding complications.11,12
The Florida sleeve is a useful aortic root remodeling technique for cardiothoracic surgeons to have in their armamentarium that entails encompassing the sinuses while narrowing the aortic annulus and sinotubular junction to preserve the aortic valve. This technique is a valuable alternative to root replacement in appropriately chosen patients. The Florida sleeve is particularly advantageous for aortic valve salvage in cases of offset coronary arteries and bicuspid aortic valve. It has even become a useful option in carefully selected aortic dissection patients. Specific attention must be paid to inspection of the coronary artery relationship to commissures, circumferential dissection below the coronaries to allow passage of the sleeve graft and subcommissural suture placement to secure the graft in place.

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How to do itThe Florida Sleeve: A New Technique for Aortic Root Remodeling With Preservation of the Aortic Valve and Sinuses

Section snippets

Technique

Results

Comment

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

How to do it
The Florida Sleeve: A New Technique for Aortic Root Remodeling With Preservation of the Aortic Valve and Sinuses