nastpnie wykonywano podspoidow plastyk , plikacj patka , cicie zwkniaego wolnego brzegu patka , komisurotomi .
i pozostaj w klasie nyha i. wyniki bada echokardiograficznych potwierdzaj dobr funkcj naprawionych zastawek aortalnych .
repair of the aortic valve has received noticeably less attention than repair of the mitral or tricuspid valves .
aortic valve repair techniques have drawn attention since carpentier reported a large number of repairs in 1983 .
the functional structure and redundancy of the mitral and tricuspid valves may be more amenable to remodeling techniques .
although this treatment strategy is justified by excellent long - term results , complications such as thromboembolism , endocarditis , and need for long - term anticoagulation   have become the driving force in the quest for a surgical procedure that will save the native aortic valve .
the aim of this study was to assess the clinical and echocardiographic outcomes after aortic valve reconstruction with a novel surgical technique consisting of : functional classification and correlation with the surgical procedure as proposed by el khoury , cusp extension , small intestinal submucosa - extracellular matrix ( sis - ecm ) patch ( cormatrix cardiovascular , inc , alpharetta , ga ) . 
  functional classification and correlation with the surgical procedure as proposed by el khoury , small intestinal submucosa - extracellular matrix ( sis - ecm ) patch ( cormatrix cardiovascular , inc , alpharetta , ga ) .
between may 2008 and october 2015 , 30 patients underwent aortic valve repair with cusp extension including 5 patients who underwent an aortic valve - sparing procedure with a david or florida sleeve .
the group consisted of 23 men and 7 women with a median age of 35 years ( range 9 to 60 years ) .
preoperative patient characteristics are shown in table i. preoperative echocardiographic assessment is shown in table ii . 
 
preoperative patient characteristics echocardiographic studies ai  aortic insufficiency , avg  aortic valve gradient all cases were approached via median sternotomy .
following cannulation of the ascending aorta and the right atrium mild hypothermic ( 32c ) cardiopulmonary bypass was commenced .
myocardial protection was achieved with antegrade cold blood cardioplegia . in patients with aortic root aneurysm ( el khoury functional classification type ib )
the reimplantation or florida sleeve technique was used . in all cases of reimplantation , sutures without teflon felt on the annulus and cusp extension instead of a running gore - tex suture
depending on the extent of the root aneurysm in cases where symmetrical widening was observed , the florida sleeve method was used .
the graft must be of an appropriate size to obtain adequate aortic valve competence . to assess the size of the prosthesis needed ,
the commissural stitches are pulled up and then brought inward until a good line of coaptation is obtained .
finally , surgical cusp extension is performed . in 11 patients with el khoury type ic lesion ,
type ii cusp prolapse was treated by plication of the free edge of the cusp in 25 patients . in 10 cases of type iii
commissural fusion was freed by blade commissurotomy ( 5 patients ) . at this stage of surgery
each strip was then sutured to the corresponding free edge of the aortic cusp using 7 - 0 gore - tex sutures .
the neo - commissures were then elevated to the height of the strip ( 8 mm ) .
( 17 patients ) the strips have been tailored from an extracellular matrix ( sis - ecm ) patch ( cormatrix cardiovascular , inc , alpharetta , ga ) .
after weaning from cardiopulmonary bypass , a complete transesophageal echocardiogram was performed to evaluate the valve function .
the primary goal was to achieve the height of the line of coaptation of the leaflets well above the plane of the aortic annulus .
analysis of variance ranks for dependent samples ( friedman anova ) was performed using statistica 12 pl .
between may 2008 and october 2015 , 30 patients underwent aortic valve repair with cusp extension including 5 patients who underwent an aortic valve - sparing procedure with a david or florida sleeve .
the group consisted of 23 men and 7 women with a median age of 35 years ( range 9 to 60 years ) .
preoperative patient characteristics are shown in table i. preoperative echocardiographic assessment is shown in table ii . 
 
following cannulation of the ascending aorta and the right atrium mild hypothermic ( 32c ) cardiopulmonary bypass was commenced .
myocardial protection was achieved with antegrade cold blood cardioplegia . in patients with aortic root aneurysm ( el khoury functional classification type ib )
the reimplantation or florida sleeve technique was used . in all cases of reimplantation , sutures without teflon felt on the annulus and cusp extension instead of a running gore - tex suture
depending on the extent of the root aneurysm in cases where symmetrical widening was observed , the florida sleeve method was used .
to assess the size of the prosthesis needed , the commissural stitches are pulled up and then brought inward until a good line of coaptation is obtained .
finally , surgical cusp extension is performed . in 11 patients with el khoury type ic lesion ,
type ii cusp prolapse was treated by plication of the free edge of the cusp in 25 patients . in 10 cases of type iii
commissural fusion was freed by blade commissurotomy ( 5 patients ) . at this stage of surgery
each strip was then sutured to the corresponding free edge of the aortic cusp using 7 - 0 gore - tex sutures .
the neo - commissures were then elevated to the height of the strip ( 8 mm ) .
( 17 patients ) the strips have been tailored from an extracellular matrix ( sis - ecm ) patch ( cormatrix cardiovascular , inc , alpharetta , ga ) . after weaning from cardiopulmonary bypass ,
the primary goal was to achieve the height of the line of coaptation of the leaflets well above the plane of the aortic annulus .
analysis of variance ranks for dependent samples ( friedman anova ) was performed using statistica 12 pl .
three patients with dilatation of the aortic root were treated using the florida sleeve technique .
the opening and closing movements of the aortic cusps were also favorable in all patients , regardless of the surgical method used for root repair . during follow - up ,
which was completed for all patients and averaged 40  30 ( range : 2 - 89 ) months , 1 patient needed reoperation at 1 year due to endocarditis .
all patients remained alive in nyha functional class i. no embolic event was recorded in the study group , where only a small dose ( 75 mg ) of daily aspirin was introduced as prevention of thromboembolism .
the reimplantation technique provided more stable valve function than remodeling during the first 10 years of follow - up in patients with aortic root aneurysm . in a recent report by david on experience with reimplantation of the aortic valve in 296 patients ,
only 3 patients required reoperation on the aortic valve and 11 developed moderate or severe aortic insufficiency . in that series ,
the freedom from reoperation at 15 years was 98% and the freedom from moderate or severe aortic insufficiency was 89% .
although remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve , long - term follow - up suggests that the latter is associated with lower risk of developing aortic insufficiency .
failure of remodeling of the aortic root is often due to dilatation of the aortic annulus .
understanding the processes underlying insufficiency progression in patients with ascending aortic pathologies , as well as the aortic root structure and function , has become the basis for the development and implementation of extravalvular exoprosthetic repair of the aortic root ( the florida sleeve procedure ) , a new approach to valve - sparing surgery for the aortic root .
the florida sleeve technique allows aortic root reconstruction to be combined with aortic valve annuloplasty .
in addition , the use of this procedure makes it possible to strengthen the aortic root and sinuses of valsalva , and to repair the sinotubular junction , and to preserve the stereometry of aortic root components .
it also eliminates the need for reimplantation of coronary arteries , cutting out the sinuses , and fixing the commissures , which in turn reduces the risk of bleeding and potential torsion of coronary arteries during reimplantation .
therefore , if aortic insufficiency is accompanied by an aneurysm of the aortic root , we would recommend reimplantation or the florida sleeve technique .
regardless of the technique used to repair the dilated aortic root , the cusps must coapt above the level of the nadir of the aortic annulus and the coaptation length must be at least 4 mm in the central part of the valve .
although the aortic valve closes at the end of systole mainly due to lowering of the axial pressure difference , also the pooling of blood into the aortic sinuses may be involved in the diastolic closing phase .
the aortic valve is exposed to laminar shear stress on the ventricular side when the blood flows past the leaflets during systole , and to oscillatory shear stress on the aortic side when blood pools into the sinuses during diastole .
the diastolic coronary flow partially induces laminar shear stress over the left and right cusps , whereas the flow over the non - coronary cusp may be solely oscillatory . interestingly , an echocardiographic study identified the non - coronary cusp as firstly affected by thickening , suggesting that lower laminar shear stress , in the absence of diastolic coronary flow , may accelerate valvular thickening .
the axial pressure acts on the basis of the aortic cusp . a surgical procedure ( according to the el khoury method : a sub - commissural annuloplasty , plication of the free edge of the cusp ,
shaving the leaflet , enucleated nodular calcifications , and commissurotomy ) may result in tightness of the aortic valve .
in contrast to the leaflet edge extension , a patch enlargement of the cusp at its base is much easier   but exposes the pericardial patch to the impact of axial pressure .
an increase in the coaptation area can also be achieved by leaflet extension , in which a pericardial strip is sewn to the free edge of the cusp .
the lack of leaflet tissue requires a leaflet extension procedure in order to increase the area of leaflet coaptation .
using three rectangular strips , the height of which was fixed at 8 mm , we have adopted a simplification of the initial technique described by duran and associates .
the material of choice for extension is still debated : glutaraldehyde - stabilized autologous pericardium , extracellular matrix patch or some other material . our previous experience with newborns operated on because of hypoplastic left heart syndrome using an extracellular matrix ( sis - ecm ) patch ( cormatrix cardiovascular , inc , alpharetta , ga ) ( fig .
small intestinal submucosa - extracellular matrix ( sis - ecm ) patch ( cormatrix cardiovascular , inc , alpharetta , ga ) 8 months after vosschulte operation , at 1 month of age .
green collagen fibers without any degenerative process are arranged closely and repopulated with some cells .
magnification 400x in a recent multicenter study   among 8 cases of aortic arch repair with the sis - ecm scaffold , no case of restenosis or aneurysm had occurred in the aortic position at mid - term follow - up . on the other hand ,
redo surgery consisted of valve replacement for failing aortic plasty in 5 out of 10 patients who had undergone leaflet extension repair with sis - ecm .
extracellular matrix scaffolds consist of structural and functional molecules secreted by the resident cells of each tissue and organ from which they are prepared .
when implanted in the host tissue , proteolytic degradation of the ecm scaffold by immunomodulatory pro - remodeling macrophages produces biochemical triggers that attract progenitor cells and , together with the surrounding biomechanical and fluid dynamic environment , induce progenitor cell proliferation and phenotypic maturation . in less than four months after being sutured into pericardium this patch has transformed into pericardium itself , and used as tubular form sutured into tricuspid valve has formed into the valve tissue . provided the shaved aortic valve leaflets were fibrous , ecm - sis patch attached might possibly form into keloid .
perhaps this factor plays an important role as compared to small forces acting to enlarge the leaflet coaptation .
we speculate , that it is not the patch itself but the way it was applied , cusp extension or suturing into the leaflet , that may influence the long - term outcome . in a paper published by padalino  
our preliminary results showed that involving : aortic valve plasty according to the el khoury functional classification , cusp extension with no tension , sis - ecm results in a good outcome and suggest that this technique should be considered as a viable procedure for surgical aortic valve repair . at the follow - up , patients who underwent aortic valve leaflet repair with leaflet augmentation presented with good functional outcome .
 introductionthe proportion of valve repair procedures is increasing in experienced centers . 
 the aim of the study was to assess the clinical and echocardiographic outcomes after aortic valve reconstruction with a novel surgical technique.material and methodsthe study group consisted of 30 patients ( 23 male and 7 female ) at a mean age of 35  14 years . in patients with aortic root aneurysm the reimplantation or florida sleeve technique was used . 
 a sub - commissural annuloplasty , plication of the free edge of the cusp , shaving , and commissurotomy were performed . at this stage of surgery 
 aortic repair was then attempted by cusp extension . since 2013 
 the strips have been tailored from extracellular matrix.resultsthe mean aortic cross - clamp time was 90  32 min . 
 the mean cardiopulmonary bypass time was 126  38 min . 
 there was no in - hospital death . 
 re - exploration for bleeding was required in 1 patient . during follow - up , 
 1 patient needed reoperation at 1 year due to endocarditis . 
 all patients remained alive in new york heart association ( nyha ) functional class i. the echocardiographic findings remained unchanged in all cases during follow-up.conclusionsour modification of aortic valve repair results in a good outcome . 
Wstp
Materia i metody
Wyniki
Wnioski
Introduction
Material and methods
Patients
Surgical technique
Statistical analysis
Results
Discussion
Conclusions
Disclosure