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• W2912014825 abstract "Aortic root reconstruction remains a formidable challenge for modern cardiac surgeons. The surgeon's ultimate goal should be the reconstitution ad integrum of the original anatomy and physiology of the ascending aorta. The aortic wall has very specific biomechanical properties that are far different from any polyester fabric currently being used in cardiac operations. Optimal cardiac work depends on these specific properties. For instance, any rise in central aortic tone or stiffness increases aortic impedance and pulse pressure, causing ventricular hypertrophy, which is an important risk factor of cardiovascular adverse events [1Mitchell G.F. Lacoursiere Y. Ouellet J.P. et al.Determinants of elevated pulse pressure in middle-aged and older subjects with uncomplicated systolic hypertension: the role of proximal aortic diameter and the aortic pressure-flow relationship.Circulation. 2003; 108: 1592-1598Crossref PubMed Scopus (233) Google Scholar, 2Roman M.J. Ganau A. Saba P.S. Pini R. Pickering T.G. Devereux R.B. Impact of arterial stiffening on the left ventricular structure.Hypertension. 2000; 36: 489-494Crossref PubMed Scopus (204) Google Scholar]. Consequently, surgical substitution of the ascending aorta (AA) by any artificial graft will indefinitely affect, to some extent, myocardial workload. This aspect should be considered in the surgeon's decision-making process. Optimal coronary perfusion and proper closure of the aortic valve also rely on specific anatomic features of the sinus of Valsalva [2Roman M.J. Ganau A. Saba P.S. Pini R. Pickering T.G. Devereux R.B. Impact of arterial stiffening on the left ventricular structure.Hypertension. 2000; 36: 489-494Crossref PubMed Scopus (204) Google Scholar, 3Bellhouse B.J. Bellhouse F.H. Reid K.G. Fluid mechanics of the aortic root with application to coronary flow.Nature. 1968; 219: 1059-1061Crossref PubMed Scopus (72) Google Scholar]. Sinuses and their leaflet counterparts are shaped as a parabola of revolution during diastolic closure of the leaflets [4Bara C.L. Verhey J.F. Simulation of the fluid dynamics in artificial aortic roots: comparison of two types of prostheses.Artif Organs. 2008; 11: 123-129Crossref Scopus (4) Google Scholar] and contribute to an even distribution of closure stress over the sinus walls and leaflets. In the long-term, this lowers fatigue and preserves these structures. The report by Matthews and colleagues [5Matthews P.B. Azadani A.N. Jhun C.-S. et al.Comparison of porcine pulmonary and aortic root material properties.Ann Thorac Surg. 2010; 89: 1981-1989Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] describes the biomechanical properties of the porcine pulmonary and aortic root aorta. Stress and strain curves were determined at the level of the sinus and supravalvular portions. Stiffness, the first derivative of the model stress-strain response, was determined at different levels of stretching to characterize the properties of the wall vessel. At a low level of stretch, where little stress causes a big deformation, elastin fibers normally dominate and determine the elastic modulus of the curve; whereas at a high level, where higher stress causes little deformation, collagen fibers dominate and determine stiffness. This biphasic nonlinear property characterizes the normal physiologic response of vessel conductance to blood perfusion. Their study determined that the sinus portion in both AA and pulmonary artery (PA) was less compliant and stiffer than in their suprasinus counterparts. This was corroborated by histologic evidence that the supravalvular arteries had a tighter and denser weave of elastin than the corresponding intrasinuses. This may be in relation to the geometric aspect that the sinus-leaflet unit achieves early in diastole to ensure proper valve closure. On the other hand, the supravalvular segment of the PA was more compliant than the AA but contained less elastin than its AA counterpart. Circumferentially, at high strain (simulating systemic pressure), the PA displays similar compliance and stiffness properties to the AA. This means that early on, after implantation, the PA autograft should perform adequately in a left-sided systemic environment. What happens after long-term remodelling is hard to predict. The smaller concentration of elastin weave in the PA wall may translate to greater long-term fatigue and faster wear. This would explain some of the pathologic autograft remodelling and dilatation that is occasionally observed after the Ross operation. As clinicians, we cannot overlook the importance of having these biomechanical studies to assess our work. In this particular study, the work of Matthews and colleagues [5Matthews P.B. Azadani A.N. Jhun C.-S. et al.Comparison of porcine pulmonary and aortic root material properties.Ann Thorac Surg. 2010; 89: 1981-1989Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar] sheds light on PA autograft adaptation as an AA surrogate in the Ross procedure. The more we learn about the biomechanical behavior of the biomaterials we use for vascular reconstruction, the better we will learn about when and how to use it. Similarly, we will be better prepared to counsel the industry in fabricating and creating more physiologically adapted artificial grafts. Pulmonary autografts and aortic homografts have been used for decades in AA reconstruction. Although generally the results are quite impressive, they are far from faultless, and these grafts carry their own problems. We have been content with Dacron grafts (DuPont, Wilmington, DE) for more than 40 years. Through the years, however, we have learned that Dacron grafts are prone to unexpected expansion and anastomotic pseudoaneurysm, which is worrisome, especially in young patients with a long life expectancy. New technologies, such as nanotechnologies and genetic engineering, along with a strong cooperation with engineers, will give us the opportunity to improve our work and provide patients with a better physiologically adapted biomaterial for reconstructive operations. This is a future development that clinicians, especially surgeons, cannot afford to ignore. Comparison of Porcine Pulmonary and Aortic Root Material PropertiesThe Annals of Thoracic SurgeryVol. 89Issue 6PreviewThe pulmonary autograft remodels when subjected to systemic pressure and subsequent dilation can lead to reoperation. Inherent material property differences between pulmonary and aortic roots may influence remodeling but are currently unknown. The objective of this study was to determine stiffness across a wide range of strain and compare nonlinear material properties of corresponding regions of native aortic and pulmonary roots. Full-Text PDF" @default.
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• W2912014825 date "2010-06-01" @default.
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• W2912014825 title "Invited Commentary" @default.
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• W2912014825 doi "https://doi.org/10.1016/j.athoracsur.2010.04.050" @default.
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