Management of the Small Aortic Root Using the "Floating Valve" Technique

Originally presented as a STSA/CTSNet Surgical Motion Picture at the 2016 STSA Annual Meeting. 

Objectives: Dealing with the small aortic root is always a challenging clinical problem, particularly in the reoperative setting, in which scarring and fibrosis of surrounding tissues reduces the flexibility of the left ventricular outflow tract. In this situation, it may not always be possible to implant an adequately sized new valve prosthesis, resulting in a degree of patient-prosthesis mismatch, and leading to high trans-valvular gradients postoperatively. The authors demonstrate their preferred solution for addressing this difficult condition.

Methods: The technique for negotiating the small aortic root is demonstrated in a 31-year-old female patient who underwent aortic and mitral valve replacement in the not-too-distant past, and who now presented with unacceptably high gradients across her old 17 mm mechanical aortic valve.

Results: As illustrated in the video presentation, a 23 mm mechanical aortic valve was able to be secured within a 26 mm Valsalva graft. The valve was sited within the graft in an extra-anatomic position, “floating” within the sinus segment, rather than being positioned at the level of the annulus. This allowed the authors to implant a significantly larger valve than would otherwise have been possible. Postoperatively, the patient had a peak gradient of only 12 mmHg across the new aortic prosthesis.

Conclusion: Positioning the new aortic valve in a “floating” position within the sinus segment of the aortic graft allows a significantly larger prosthesis to be implanted than would otherwise be possible based on the diameter of the aortic annulus alone. The authors suggest that surgeons consider this technique when attempting to negotiate the small aortic root.

Copyright 2016, used with permission from the Southern Thoracic Surgical Association. All rights reserved.