Transthoracic echocardiography for selection of tubular graft size in David reimplantation technique

OBJECTIVES Selection of tubular graft size during David reimplantation technique for aortic root dilatation is based on perioperative leaflet height measurements. The present study evaluated whether transthoracic echocardiography (TTE)-based algorithms may help in selecting the graft size preoperatively. METHODS Thirty patients (52 ± 11 years old, 73% men) who underwent David reimplantation technique were evaluated. The implanted graft size was based on the David's formula. Leaflet height [diameter = 1.1 × ((2 × 2/3 × leaflet height) + 2)), leaflet length (diameter = ((2 × 2/3 × leaflet length) + 2)] and leaflet area [diameter = 0.8 × ((2 × âš(total leaflet area/π)) + 2)] TTE-derived formulas were retrospectively developed. The percentage of under-or oversized implanted grafts was calculated and the association between the adequacy of graft sizing using TTE-derived formulas and the incidence of residual aortic regurgitation (AR) was evaluated retrospectively. RESULTS The incidence of postoperative mild residual AR was 23%. The true diameter of the inplanted graft was oversized based on leaflet height in 15 (50%) patients, based on leaflet length in 13 (43%) patients and based on leaflet area TTE-derived formula in 11 (37%) patients. The incidence of mild AR was significantly lower in undersized grafts compared with oversized grafts based on leaflet length TTE-derived formula (6 vs 46%, P = 0.032) and leaflet area TTE-derived formula (5 vs 55%, P = 0.009). CONCLUSIONS In patients undergoing David reimplantation technique, grafts considered undersized according to the leaflet length or leaflet area TTE-derived formula were associated with less incidence of residual AR than patients with oversized grafts.