The Florida Sleeve
with supplementary images and video
by Phillip Hess, MD, Thomas Beaver, MD, Charles Klodelland, MD, and Tom Martin M.D.
The Florida Sleeve is a new technique that simplifies and unifies the technique for sparing the native aortic valve while still eliminating the ascending aortic aneurysm. Developed by Tom Martin, MD, at The University of Florida, Gainesville, this new procedure vastly simplifies the surgical challenges of reconstructing the native valve affected by annular dilatation.
The normal aortic root diameter is between 23 mm and 27 mm in the adult. Annuloaortic ectasia is a condition where the aortic root dilates, leading to separation of the aortic valve leaflets and central regurgitation. In more advanced cases (root diameters above 40 mm), stress on the leaflets causes tearing, perforations, and finally leaflet prolapse. Once the leaflets are destroyed, the valve cannot be spared. However, in less severe cases (annuli between 30 mm and 40 mm), the valve leaflets often remain normal and yet are too far apart for coaptation, leaving the valve with varying degrees of regurgitation.
For patients who still have relatively normal leaflets, reconstruction of the aortic root and annulus can result in a preserved and competent native aortic valve while still removing the supra-coronary aneurysm. Valve sparing root replacement was first described by Tirone David from Toronto. His David 1 procedure has now been used by many centers with success. In the David 1, the walls of the Sinuses of Valsalva are resected and the native valve is reimplanted inside a Dacron conduit anchored to the aortic annulus. By reducing the annuluar dimension to that of the rigid conduit, the annulus is not allowed to dilate in the future (analogous to using a ring annuloplasty in mitral valve reconstruction).
The difficulty with the David 1 approach is judging where to reimplant the native valve commissures. If the commisures are not positioned correctly within the Dacron sleeve, the leaflets may not coapt properly, leading to aortic regurgitation. Judging the size of the Dacron sleeve as well as the position of the reimplanted commissures can be difficult and inexact, especially for surgeons just beginning their experience with valve-sparing root replacement.
The Florida Sleeve is a new technique that simplifies and unifies the technique for sparing the native aortic valve while still eliminating the ascending aortic aneurysm. Developed by Tom Martin, MD, at The University of Florida, Gainesville, this new procedure vastly simplifies the surgical challenges of reconstructing the native valve affected by annular dilatation. The Florida Sleeve is indicated in patients with ascending aortic aneurysms or dissections where the structure of the native valve leaflets remain normal. Patients with aortic regurgitation due to dilatation of the annulus are the best candidates, including those with Marfan syndrome.
The key differences between the Florida Sleeve and other valve-sparing root replacements are the following: (1) the sinus walls are not resected and coronary buttons are not created, (2) the coronary arteries do not need to be reimplanted, (3) the valve is not reimplanted, (4) the sinus walls are reduced and supported by an external Dacron conduit that stabilizes the diameter of the annulus so that future dilatation cannot occur, (5) the size of the annulus and sinotubular ridge are measured with obturators (Hegar dilators, valve sizers, etc) to obtain a uniform and consistent reduction in diameter without guess work, and (6) since the sinus walls are not resected, there is no potential for bleeding at the proximal suture line and thus less sutures are needed.
The attached movie filmed at the University of Florida, Gainseville, by Dr. Martin and his team demonstrates the entire Florida Sleeve procedure. Photographs of a recent case performed at Hutchinson Hospital, Hutchinson, Kansas by Dr. Mark Levinson illustrate the anatomy and final result.
The basic principles of the Florida Sleeve are as follows. The aorta is transected just above the sinotubular ridge and the external wall of the aortic root is mobilized from surrounding tissue until the junction between the aorta and ventriclar muscle is visible. Horizontal mattress sutures are placed underneath the commissures and brought out externally. Instead of coronary buttons, keyholes are created in the graft and the coronary arteries are slid into these openings. The graft is tied down over a sizer and the slits in the keyholes are reapproximated.
Below is a detailed step-by-step description of the Florida Sleeve that supplements the illustrations provided by the movie and photographs.
1. Transect the aorta about 8 mm to 10 mm distal to the sinotubular junction.
2. Mobilize the external tissues away from the aortic wall using careful blunt dissection technique with complete preservation of the coronary ostia. The space underneath each coronary ostia must also be mobilized. To prevent bleeding from the ventricular muscle, the tissues should be brushed away from the aortic wall.
3. Identify the fibrous annulus from the outside (where the aorta joins the ventricular and/or atrial muscle).
4. Size the annulus with a Hegar dilator or mechanical St. Jude valve sizer. The ideal diameter for reconstruction is between 24 mm and 26 mm internal dimension.
5. Using pledgetted 2-0 permanent suture such as Tevdek or Ethibond, horizontal mattress sutures are taken from inside of each commissure but at the depth of the lowest point of each leaflet. A total of 4 sutures are used and held into an external suture holder.
- One suture is placed underneath each commissure but at the level of the lowest point (nadir) of the nearby leaflets.
- One suture is placed at the mid point (nadir) of the noncoronary sinus, using a somewhat wider bite.
- The suture used under the L-R commissure is slightly higher than the other (to prevent buckling of the coronary ostia).
6. Choose a graft that remodels the sinuses to a more normal final diameter, bringing the leaflets into closer proximity to each other. In the adult, the optimum internal annular diameter is between 24 mm and 26 mm. A 30-mm or 32-mm graft external to the aortic root tissue results in an internal diameter of about 26 mm for the valve apparatus itself. For the minimally dilated annulus, a 30-mm to 32-mm graft is usually fine. For markedly dilated sinuses, a 32-mm to 34-mm graft works best. If using the Valsalva graft, trim it proximally until just 2 or 3 rings of cloth remain below the Valsalva section (usually a 30 Valsalva graft or 32 straight graft gives the correct final dimensions).
7. Pass the sutures through the lower edge of the Dacron graft. Slide the graft down over the native aortic root and mark the position of the coronary ostia onto the cloth using a blue marking pen. Usually, the space between the bottom of the coronary artery and where the sutures exit is about 1 cm. Now raise the graft back up using the sutures as guides to keep the graft oriented. With scissors or an opthalmic cautery, cut a hole in the graft to match the size and position of each coronary ostia. Leave enough room inside this opening so the coronary artery will not be compressed. Now cut vertically through this opening down to the bottom edge of the Dacron sleeve. This creates a keyhole through which the coronary artery is positioned in the next step.
8. Slide the Dacron sleeve down to the base of the root and position each coronary ostia within their respective keyholes.
9. Position a Hegar dilator or valve sizer across the valve, usually about 25 mm or 26 mm in diameter. This prevents the annulus from being kinked and becoming too small as the sutures are being tied.
10. Tie the 4 basal anchoring sutures using the Hegar dilator as a mandril to ensure the final and accurate root diameter. Tie the suture at the L-R commissure a little loosely or it can cause leaflet prolapse.
11. Close the vertical slit under each keyhole using 2 or 3 interrupted sutures.
12. Trim the Dacron sleeve to match the heigth of the preserved aortic root (just beyond the native STJ)
13. With the reconstructed root held up vertically, the valve should now be competent when filled with saline.
14. The top of the graft is reapproximatted to the edge of the transected aortic root with a 4-0 prolene continuous horizontal mattress suture. This suture is just to anchor the graft distally and does not need to be fully hemostatic since the Dacron is only an external gusset.
15. Lastly, join the reconstructed root to the ascending aorta (or any replacement graft used after resecting an ascending aneurysm) with running 3-0 prolene. Most commonly, the aneurysmal ascending aorta is replaced with a 26 or 28 graft up to or beyond the innominate artery. Joining this 26 graft to the 32 Florida Sleeve graft with a single running prolene anastomosis reconstructs the sinotubular ridge dimensions as best possible.
16. Once off cardipulmonary bypass, intraoperative TEE should verify minimal aortic regurgitation (1+ or less).
Supplementary materials:
Figure 1: 5cm ascending aortic aneurysm with 2+ aortic regurg.
Figure 2: Preserved native valve leaflets with subannular repair sutures.
Figure 3: Completed ascending and root reconstruction.
 Video: The Florida Sleeve (External Dacron Graft Reinforcement of the Aortic Root)
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