Medium-Term Outcomes After Implantation
of Expanded Polytetrafluoroethylene
Valved Conduit
Yoshio Ootaki, MD, PhD, Allison S. Welch, PA, Michael J. Walsh, MD,
Michael D. Quartermain, MD, Derek A. Williams, DO, and Ross M. Ungerleider, MD
Divisions of Cardiothoracic Surgery and Pediatric Cardiology, Wake Forest Baptist Health, Winston-Salem, North Carolina
Background. Pulmonary valve replacement is
becoming the most frequent congenital heart surgery
performed on adolescents and young adults. Numerous
surgical options are available, including autologous
pericardium, mechanical valves, allografts, and bio-
prosthetic valves. Each option has limitations with dura-
bility and freedom from reintervention for stenosis or
insufficiency, particularly in the pediatric population.
The purpose of this study was to analyze our uniquely
designed, expanded polytetrafluoroethylene (ePTFE)
valved conduit (VC) for right ventricular outflow tract
reconstruction.
Methods. Beginning in 2012, ePTFE VC were implan-
ted in 26 patients with a median age of 9.8 years (range,
1.0 to 15.9). Bicuspid VC were used in the first 3 patients,
and tricuspid VC were used in 23 patients. The ePTFE VC
is fashioned from commercially available ePTFE tube
graft (16 mm in 1 patient, 20 mm in 7 patients, 24 mm in
P ulmonary valve replacement is becoming the most
frequent congenital heart surgical procedure
performed on adolescents and young adults. Numerous
surgical options are available and included autologous
pericardium [1], mechanical valves [2] (although these are
not commonly used in the pulmonary position), allografts
[3], and bioprosthetic valves (both as stented and freestyle
porcine valves [4, 5] and as bovine jugular vein conduits
[6]). More recently, there is growing enthusiasm for
percutaneously inserted bioprosthetic valves [7]. How-
ever, percutaneously inserted valves have demonstrated a
disturbingly high incidence of subacute bacterial endo-
carditis in addition to stent fracture and risks for late
valve dysfunction [8]. None of these options is ideal, and
each has problems with durability and freedom from
stenosis or insufficiency requiring reoperation,
particularly in the pediatric population.
Accepted for publication July 10, 2017.
Presented at the Sixty-third Annual Meeting of the Southern Thoracic
Surgical Association, Naples, FL, Nov 9–12, 2016.
Address correspondence to Dr Ootaki, Wake Forest Baptist Health, Pe-
diatric Cardiothoracic Surgery, Medical Center Blvd, Winston-Salem,
NC 27157; email: yotaki@wakehealth.edu.
Ó 2017 by The Society of Thoracic Surgeons
Published by Elsevier Inc.
18 patients) and 0.1 mm thick ePTFE membrane for the
leaflet material. Valve function was assessed by echo-
cardiogram after the implantation.
Results. There were no postoperative hospital deaths.
Mean follow-up was 2.6 years (range, 4 months to 4.7
years), and there have been no reoperations for the ePTFE
VC. There was one reintervention for stenosis at the distal
anastomosis. Pulmonary insufficiency was mild or less in
24 patients (92%). The average peak instantaneous pres-
sure gradient between the right ventricle and the pulmo-
nary artery was 22.4 ± 15.1 mm Hg at latest follow-up.
Conclusions. Compared with historical data for other
pulmonary valve replacement options, our ePTFE VC
shows superior medium-term performance, with less
reintervention or significant valve dysfunction.
(Ann Thorac Surg 2017;-:-–-)
Ó 2017 by The Society of Thoracic Surgeons
Expanded polytetrafluoroethylene (ePTFE) has been
reported for use in pulmonary valve replacement [9–18].
Monocusp valves were reported in 2002 [9]; and bicuspid
valves have been created in situ, and more recently, in
conduits [13, 15]. Intermediate term follow-up with
respect to freedom from significant valve deterioration
has been excellent. Tricuspid valves have been created
primarily in Japan where allografts have not been widely
available [10–12]. The follow-up now exceeds 10 years
with excellent results. Construction of these valves, as
described in the literature, has seemed somewhat
complicated, however. In 2013, we described our
innovative technique of simplified tricuspid ePTFE valved
conduit (VC) construction and implantation, which
consists of commercially available ePTFE graft and 0.1
mm thick ePTFE membrane (W.L. Gore & Associates,
Flagstaff, AZ) [19]. The purpose of this study is to review
the medium-term outcomes of our ePTFE VC.
Patients and Methods
Patients
From January 2012 to May 2016, we implanted a bicuspid
ePTFE VC in 3 patients and a tricuspid ePTFE VC in 23
patients. The median age at the time of implantation was
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2017.07.013
2 OOTAKI ET AL
TRICUSPID EPTFE VALVE
9.9 years (range, 1.0 to 15.9). Patients’ median body weight
was 28.9 kg (range, 7.8 to 64.9 kg). Three sizes of VC were
used depending on the patient’s body size and preoper-
ative right ventricular outflow tract measurement: 16 mm
in 1 patient, 20 mm in 7 patients, and 24 mm in 18
patients. Primary diagnosis included tetralogy of Fallot in
15 patients, truncus arteriosus in 3 patients, aortic
valvular disease in 4 patients, and other pulmonary valve
disease in 4 patients. Twenty-four patients (92%) had a
history of median sternotomy. Concomitant procedure at
the time of ePTFE VC implantation included Ross
operation in 4 patients, closure of atrial septal defect in 3
patients, closure of ventricular septal defect in 1 patient,
and mitral valve replacement in 1 patient. Currently,
patients who require pulmonary valve conduits smaller
than 16 mm or larger than 24 mm receive other options
such as allografts or bioprosthetic valves.
Fig 1. Bicuspid (left) and tricuspid (right) expanded polytetrafluoroethylene valved conduit in open (top) and closed (bottom) position.
Ann Thorac Surg
2017;-:-–-
This research study was approved by the Institutional
Review Board at Wake Forest School of Medicine.
Construction of the Conduit
We construct this VC using commercially available PTFE
conduits (16 mm, 20 mm, or 24 mm) and 0.1 mm thick
PTFE membrane for the leaflet material. After the patient
is intubated, the surgeon creates the conduit on a sterile
table. A bicuspid VC is created using the technique
described by Quintessenza and associates [13], and a
tricuspid VC is created using our unique technique,
which has been previously described (Fig 1) [19].
Depending on the size of the VC, we create a PTFE
membrane with three equal-sized leaflets, according to
the formula in Figure 2.
A 24-mm PTFE conduit is then cut to about 6 cm in
length. The conduit does not need to be longer, and making
Ann Thorac Surg
2017;-:-–-
Fig 2. Creating trileaflet expanded polytetrafluoroethylene (ePTFE)
valved conduit. (A) Create a piece of 0.1-mm ePTFE membrane that is
18 mm in height by 78 mm long for 24 mm valved conduit. (B) Fold
the ePTFE membrane into thirds. (C) Leave 5 mm on the top, and cut
the bottom into an appropriate sinus shape. (R ¼ radius.)
it too long hampers valve construction. The conduit is
inverted so that the valve leaflets can be created on the
outside. The leaflet material is placed 1.5 cm down from the
top of the conduit. The commissures of each leading edge
are brought together and connected using CV-6 PTFE
suture (W.L. Gore & Associates). We choose to tie the knots
on the “inside” of the conduit, which will be the outside
OOTAKI ET AL 3
TRICUSPID EPTFE VALVE
once the conduit is reinverted. Once the leaflet material is
wrapped around the conduit, we fix each of the other
commissural apposition areas with different sutures in
symmetrical positions. All three leaflets are sewn using
continuous sutures. After sewing the three leaflets to the
surface of the conduit, the tube graft can be reinverted,
bringing the leaflets to the inside. Commissure sutures
using 6-0 monofilament sutures are placed to create
sinuses. We place these in a vertical mattress fashion at the
opposing edges of the valves. We then confirm that the VC
can hold saline. An arrow (drawn with a sterile marking
pen) is used to mark the direction of flow and is placed on
the top of the conduit in a location that leaves a commissure
directly posterior. It usually takes about 60 minutes to
construct a tricuspid VC.
Echocardiographic Evaluation
The implanted VC were assessed using transesophageal
echocardiography in the operating room immediately
after surgery and transthoracic echocardiogram for
follow-up imaging. The pulmonary regurgitation was
classified as trivial (0), mild (1), moderate (2), and severe
(3). Peak instantaneous pressure gradient was assessed by
measuring peak velocity through the conduit.
Statistical Analysis
Univariate analysis for survival, freedom from reinter-
vention, and freedom from replacement of ePTFE VC
were performed using the Kaplan-Meier method. All
analysis was carried out using Microsoft Excel (Microsoft,
Redmond, WA).
Results
Of the 26 patients in our cohort, there were no hospital
deaths after implantation. Mean follow-up was 2.6 years
(range, 4 months to 4.7 years). One patient who had a
Ross operation and implantation of an ePTFE VC in the
pulmonary position with an uneventful hospital course
died 15 months after the surgery for unknown reasons
(Fig 3). This patient showed no regurgitation and minimal
pressure gradient (peak of 20 mm Hg) in the ePTFE VC at
14-month follow-up. Overall patient survival was 95.5% at
4 years. There was one reintervention during the follow-
up period for moderate stenosis at the distal ePTFE VC
suture line (Fig 4). Freedom from death and reinterven-
tion was 90.7% at 4 years. There were no reoperations for
failed ePTFE VC. There was no significant difference in
survival or reintervention rate between groups of leaflet
design or size of the ePTFE VC.
Figure 5 shows the echocardiographic peak instanta-
neous pressure gradient through the VC. The average
peak instantaneous pressure gradient between the right
ventricle and the pulmonary artery measured by echo-
cardiogram was 22.4
15.1 mm Hg in latest follow-up
echocardiogram. One patient had a 65 mm Hg pressure
gradient and trivial pulmonary regurgitation by
echocardiogram 1 day after the surgery. Cardiac cathe-
terization the next day showed a 28 mm Hg peak-to-peak
pressure gradient between the right ventricle and
4 OOTAKI ET AL Ann Thorac Surg
TRICUSPID EPTFE VALVE 2017;-:-–-

Fig 3. Kaplan-Meier curve of survival.

Fig 5. Pressure gradient through the conduit measured by echocardio-

pulmonary artery. His echocardiogram pressure gradient gram (peak).
decreased during the subsequent follow-up period;
however, the peak pressure gradient by echocardiogram
with allografts have been excellent, especially in neonates
increased to 65 mm Hg at 19-month follow-up. Cardiac
and infants; however, valve deterioration over time has
catheterization showed a 36 mm Hg pressure gradient at
been an issue, especially in smaller allografts [20].
the distal anastomosis. The pressure gradient decreased
Freedom from explantation for age less than 10 years at
to 12 mm Hg after balloon dilation. Pulmonary valve
implantation was 78.9% in 5 years, 59.6% in 10 years, and
function was excellent, and there was no pulmonary valve
32.5% in 15 years. In some countries, like Japan, allografts
regurgitation before or after the reintervention. Figure 6
are not widely available. Bovine jugular VC has been an
demonstrates the pulmonary regurgitation of the ePTFE
alternative to allografts since 1999. Early results are also
VC assessed by echocardiogram. Two patients (7.7%)
excellent although valve deterioration or endocarditis has
showed moderate pulmonary regurgitation, although
been an issue in long-term use [6]. Freedom from catheter
neither had any clinical symptoms. Three patients (11.5%)
intervention and conduit replacement in 5 years was
showed mild pulmonary regurgitation, and 21 patients
82.7% and 82.1%, respectively. Stented or nonstented
(80.8%) showed trivial pulmonary regurgitation. One
bioprosthetic valves have also been a preferred option in
patient had suspected infective endocarditis due to fever
some centers; however, valve deterioration is an issue for
and thickened anterior ePTFE leaflet. The patient was
long-term use of these valves [4, 5]. Lee and associates
treated successfully with antibiotics. No other patients
[21] compared the performance of three types of bio-
demonstrated any signs of late endocarditis.
prosthesis (stented porcine, stented bovine pericardial,
and stentless porcine valves). They reported freedom
Comment from repeat pulmonary valve replacement at 10 years was

Many materials have been used for pulmonary valve

replacement in the pediatric population. Allografts have
been widely used for more than 50 years. Early outcomes

Fig 6. Pulmonary regurgitation assessed by echocardiogram: 0 ¼

trivial, 1 ¼ mild, 2 ¼ moderate, 3 ¼ severe. Latest echocardiogram
showed trivial pulmonary regurgitation in 21 patients (80.8%), mild
Fig 4. Kaplan-Meier curve of freedom from death or reintervention. in 3 patients (11.5%), and moderate in 2 patients (7.7%).
Ann Thorac Surg
2017;-:-–-
84.6% for stented bovine pericardial valves, 48.5% for
stented porcine valves, and 31.2% for stentless porcine
valves [21]. Recently, there has been growing enthusiasm
for percutaneously inserted bioprosthetic valves.
However, endocarditis and early deterioration has been
seen in large cohort studies [7, 8]. None of the valves
discussed provide consistently reliable and excellent
outcomes, especially in the pediatric population.
Prosthetic VC using ePTFE were first described by a
Japanese group in 2002 [10]. Valve function was well
preserved in these patients for as long as 10 years.
Techniques described in the literature have utilized
creation of bulging sinuses, but creation of these valves is
cumbersome [10], and there have been no defined
benefits for this technique. Several other investigators
reported techniques to create bicuspid [13, 15] or
tricuspid [14, 16] ePTFE VC, but other techniques for
tricuspid valves are difficult to recreate. Our tricuspid VC
is simple to create and easy to implant compared with
bicuspid VC because of its shorter length. It takes less
than 60 minutes to create our tricuspid ePTFE VC without
difficulty. Review of the literature demonstrates that
freedom from reintervention or valve replacement seems
to be substantially better for ePTFE VC compared with all
other types of valves. Shinkawa and associates [18]
reported the freedom from reintervention rate for ePTFE
VC was 83.7% at 5 years, which is slightly lower than our
experience, but their technique with valve creation was
also more cumbersome. When severe conduit insuffi-
ciency or an instantaneous pressure gradient greater than
50 mm Hg through the conduit was considered conduit
OOTAKI ET AL 5
TRICUSPID EPTFE VALVE
malfunction, valve function was well maintained in 75%
of patients at 5 years [18], which is also slightly lower than
our experience. Because we only utilized pulmonary
valve conduits of 16 mm, 20 mm, and 24 mm, the size of
the conduit might contribute to the reintervention rate.
There has been no standardized description for design
of an ePTFE VC although the anatomy of the normal
heart valve suggests that a tricuspid geometric construc-
tion would be an appropriate model for an ePTFE VC. To
appreciate the measurements that guide the creation of
our valve, it is essential to understand the geometry of
normal tricuspid valves. Although there are some differ-
ences between aortic and pulmonary valves, the data on
normal aortic leaflet anatomy are well described and
easily translated to the tricuspid configuration for our
pulmonary VC. In an elegant manuscript describing
aortic valve anatomy in 100 healthy human hearts, the
height of each cusp is 50% of leaflet length [22]. Therefore,
the length of each leaflet is a critical factor in determining
the height of the leaflet. The study also showed that there
is a 5-mm coaptation area for each leaflet.
When constructing a PTFE valve, the height of the
leaflet (and thus the length of the conduit) can differ
substantially depending on whether a bicuspid or
tricuspid construction is employed. In a bicuspid con-
struction, the leaflet length is multiplication of 3 radius
plus 2 mm (Fig 7). In a tricuspid valve, each leaflet length
is multiplication of 2 radius plus 2 mm, which calculates to
a leaflet length shorter than what is needed for a bicuspid
valve. The importance of leaflet length in determining
height is illustrated in Figure 7, which demonstrates
Fig 7. Leaflet design for
bicuspid (left) and tricuspid
(right) expanded polytetra-
fluoroethylene valved
conduit. (R ¼ radius.)
6 OOTAKI ET AL
TRICUSPID EPTFE VALVE
construction of a 24-mm VC. For a bicuspid valve, the
length of each leaflet is 3 radius, or 36 mm. Because of the
relatively less pliable features of ePTFE compared with
human valve tissue, we have been using a leaflet height
that is 70% of the leaflet length. For this example, 70% of
36 mm calculates to a leaflet height of 25.2 mm, and we
add an additional 1 mm to account for material needed for
holding sutures, giving a leaflet height of 26.2 mm. For a
tricuspid valve, the leaflet length is 2 R, or 24 mm, and
70% of this size calculate a leaflet height of 16.8 mm, but
again we add an additional 1 mm to allow for suturing
(17.8 mm). Therefore, the tricuspid VC can be shorter than
a bicuspid VC—in the case shown, by nearly 1 cm—and
that can provide a substantial advantage during surgical
implantation. This consistently “shorter” height for
tricuspid versus bicuspid valves was validated in the pa-
per describing leaflet height in bicuspid and tricuspid
aortic valves [23]. Bicuspid aortic valves have greater
leaflet heights compared with leaflets in tricuspid aortic
valves. We do not have detailed in vitro valve perfor-
mance data in different configuration. These data would
help for designing best ePTFE valved conduit in the
future.
Another possible advantage of tricuspid VC is closing
position of the leaflet itself. To have full opening of the
bicuspid VC, one half circumflex length of VC is neces-
sary for each leaflet length. Conversely, one third
circumflex length of VC is necessary for each leaflet
length to have full opening of the tricuspid VC (Fig 7). The
leaflets are positioned in a nonlinear shape at the closing
phase in the bicuspid configuration, but the leaflets face
straight into each other at the closing phase in the
tricuspid configuration. We believe that this physiologic
valve anatomy in tricuspid configuration would have an
advantage over bicuspid configuration in terms of valve
function, especially when the leaflet becomes thicker over
time [24].
Long-term data are available after ePTFE VC
placement from Japan [12] and percutaneously inserted
bioprosthetic valves from a multicenter study in the
United States [7]. Although we need information more
than 10 years after percutaneously inserted bioprosthetic
valves, the ePTFE VC has advantages in terms of freedom
from reintervention. Percutaneously inserted bio-
prosthetic valves also have a limitation in patients who
have large right ventricular outflow tracts. Therefore, our
current recommendation for replacing right ventricular
outflow tract is using ePTFE VC. If the size of the right
ventricular outflow tract is appropriate, percutaneously
implanted bioprosthetic valves would be an option.
Although we have not surgically replaced any ePTFE VC,
a percutaneously implanted bioprosthetic valves would
be an option, as we believe the ePTFE VC to be a perfect
“landing zone.” We did not consider smaller-sized ePTFE
VC (less than 16 mm) for smaller children, but that could
be an option because the ePTFE VC works well even with
smaller diameter [24].
There are several limitations to this study. This study
was not randomized to assess various types of right
ventricular outflow tract VC, and we could not directly
Ann Thorac Surg
2017;-:-–-
compare our outcomes with other types of VC. Our
patient population is relatively older, and we did not
implant VC size smaller than 16 mm. However, our
freedom from reintervention or reoperation seems to be
lower compared with other types of VC from numerous
published reports. Our study is also limited by a relatively
short follow-up period. Early and intermediate results are
excellent for our ePTFE VC. However, long-term data will
be important as valve function in most other types of VC
deteriorates significantly after 10 years. We are
encouraged by the Japanese data that have followed these
patients for more than 10 years, and we are optimistic that
our outcomes, in light of current data, will be similar and
excellent. We will continue to follow up the valve function
of our ePTFE VC. Finally, echocardiographic assessment
of pulmonary insufficiency is difficult to quantify, and we
must rely on qualitative assessments for this study.
In conclusion, a tricuspid ePTFE VC can be easily
constructed in a size appropriate for pediatric patients.
Compared with historical data for other pulmonary valve
replacement options, our ePTFE VC shows superior
medium-term performance, with less reintervention or
significant valve dysfunction. Compared with previously
described bicuspid conduits, our tricuspid VC has (1)
shorter cusp height in each sinus—allowing for the entire
valve length to be shorter; (2) more physiologic coaptation
of the valve leaflets (linear versus nonlinear); and (3)
potentially improved hemodynamics at high flow rates.
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DISCUSSION
DR JAMES A. QUINTESSENZA (Lexington, KY): Great work,
Yoshio and Ross. The need for better solutions for our ever
growing population of patients for right ventricular outflow tract
continues, and there are many options available for these pa-
tients, which underscores the fact that we really do not have a
great solution. An ideal valve might be one that is viable, able to
repair itself, nonthrombogenic, will grow with the patient, be
easy to implant, and inexpensive—and clearly, that does not
exist. So most patients now receive a bioprosthesis with really
good intermediate results, but all of these we know will ulti-
mately fail along a biodegenerative curve, which looks really
good for about 5 years and then they start having a decay.
Your group at Wake Forest has continued to present on this
series of patients, which actually was presented at the 2013
meeting here, your initial series. This is a continuation of that.
And it is really about an expanded polytetrafluoroethylene
(ePTFE) valve, a synthetic, nonbiologic valve, which really has
favorable hemodynamics, is nonthrombogenic, reasonably du-
rable, and durability, especially if we refer to the literature from
Japan, which has some reports up to 10 years with 95% freedom
from failure. So it really has the potential for great durability.
This valve that you present seems to be a bit simpler than some
of the Japanese reports, and specifically it avoids the need for
bulging sinuses, and there are none in your valve. And this
brings me to my first question. What are your thoughts about the
bulging sinuses for these types of prostheses? What function do
they provide and do you do anything in your technique that
obviates the need for creating these bulging sinuses?
DR OOTAKI: First of all, thank you so much for teaching me
how to make a bicuspid valve. It is excellent. But after implan-
tation in 3 patients, actually I noticed that the height is longer, so
that is why I started a tricuspid leaflet.
OOTAKI ET AL 7
TRICUSPID EPTFE VALVE
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reconstruction. Ann Thorac Surg 2015;100:129–37.
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(ePTFE) valved conduit for right ventricular outflow tract.
Presented at the 60th annual meeting of the Southern
Thoracic Surgical Association, Scottsdale, AZ, Oct 30–Nov 2,
2013.
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188 consecutive homografts implanted in pulmonary
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133–42.
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24. Yamashita E, Yamagishi M, Miyazaki T, et al. Smaller-sized
expanded polytetrafluoroethylene conduits with a
fan-shaped valve and bulging sinuses for right ventricular
outflow tract reconstruction. Ann Thorac Surg 2016;102:
1336–44.
Our idea is totally different from the valve (in Japan), and for
the aorta, yes, we need a sinus to protect the coronary artery. I do
not know the exact answer for the pulmonary valve. And we are
creating some kind of small sinus after putting a stitch into each
commissure. So maybe this can help to prevent the open stuck
position, I think.
DR QUINTESSENZA: I noticed that thrombosis does not seem
to be a problem. I thought these patients were on aspirin. Can
you comment in terms of thrombogenicity or what you are doing
to avoid thrombosis if anything?
DR OOTAKI: Actually we did not give anything for the patient,
because I believe the Japanese group did not give anything
after surgery, and they had nice results. I really respect their
results. So we did not. This is a cheap drug, and to prevent such
kind of thing maybe it is beneficial. Also at this time I do not
have any explantation of the valve, so I do not know. If I see at
least 1 or 2 patients, then I may start giving some aspirin, I
think.
DR QUINTESSENZA: There are some data that suggests aspirin
inhibits the thickness of neointimal hyperplasia on ePTFE, so it
may be of value.
And just a final question. Do you have any plans to proceed
with a transcatheter version of this valve? Interestingly, I saw a
report last year from Shanghai demonstrating a transcatheter
ePTFE valve as a proof of concept model in a sheep. So this may
be an interesting avenue to pursue with these types of valves,
that might provide improved durability compared with our
available Melody or Sapien valves. Also, the ability to compress
the ePTFE material into a smaller diameter delivery system may
be another advantage over thicker biologic tissue.
8 OOTAKI ET AL
TRICUSPID EPTFE VALVE
DR OOTAKI: I did not see that paper. It was 3 years ago, and I
did a same comment. If I have time, I really would like to make
some kind of percutaneous version, but I could not. This valve is
the best valve so far, I think, but nothing came out for
commercialization. Gore-Tex has a patent that they filed in 2014,
and nothing comes up in the market. The idea is there, but
creating such kind of materials in the market is pretty tough, I
think.
DR KRISTINE GULESERIAN (Miami, FL): Jim, one comment
just to maybe answer your question about having the sinuses.
When I was in John Mayer’s laboratory trying to bioengineer
pulmonary valves, of course we went back to look at the history,
and Leonardo Da Vinci has described the sinuses of Valsalva
beautifully. And the other piece that is sort of missing is the node
of Arantius to help with the central coaptation. And in compu-
tational flow dynamic studies, at least in bioengineered valves,
without the sinuses, the leaflets when they open hit the wall, and
that can affect their long-term durability in terms of creating
shear stress at the mid leaflet. With PTFE, one would think you
would not need to have that concern, but I do not know that we
really know the answer to that question.
DR QUINTESSENZA: There is that little plication stitch that is
right there at the commissure, so that kind of reduces the
excursion of the leaflet all the way to the wall, that would limit it a
little bit, and maintain that potential space so that during the
Ann Thorac Surg
2017;-:-–-
regurgitant flow or the diastolic flow that fills up with blood,
essentially, and drives the leaflet toward the center. I presume
that is the mechanism or part of the mechanism for closure and
the need for those little commissural plication stitches.
DR TAKESHI SHINKAWA (Little Rock, AR): We presented our
ePTFE tricuspid valved conduit result 3 years back at the STSA
meeting. The outcome was great. And I just want to comment
that we believe that the sinus of Valsalva did affect the longevity.
We started our Gore-Tex conduit in 2008, and we started with
bicuspid, changed it to tricuspid and changed the sinus of Val-
salva. So probably we can report a difference in the future.
My other comment is about stitching the Arantius node in the
middle leaflet, I was also part of the Japanese group, and we
made a nodule in the middle leaflet in the first series; however,
we saw more calcification, so the Japanese group stopped doing
it. That is for information. Thank you.
DR OOTAKI: Thank you so much. It is good to have sinuses if
we can, but honestly when I see the first paper from Japan, oh, no
way I can make it, right? I believe all of the surgeons here, you
can make this valve, and I think this is the easiest way and the
simplest way and still have a nice result, I believe. I believe just a
few surgeons are using these ePTFE valves, but you should
change your mind and you should try. I have several patients
who are waiting for conduit repair after their homograft (im-
plantation). I think homograft is not a good solution.