Florida sleeve procedure for type II aortic regurgitation with aortic root enlargement: a case report

Florida sleeve procedure is an operative technique for aortic root reconstruction that offers advantages such as reduced bleeding risk, shorter operation time, and improved formation of the atrioventricular junction (AVJ) and sinotubular junction (STJ). In our department, we perform a Florida sleeve procedure for aortic regurgitation (AR) associated with aortic root enlargement of less than 40 mm in diameter of the Valsalva sinus. Here, we present a case of severe type II AR with aortic root enlargement where we successfully performed Florida sleeve procedure and augmented it with autologous pericardium.

A 62-year-old male patient was referred for cardiovascular surgery after a transthoracic echocardiogram indicated left ventricular enlargement and severe AR. Preoperative multidetector computed tomography (MDCT) revealed AVJ of 28.2 mm, Valsalva sinus of 38.4 mm, STJ of 36.1 mm, and ascending aorta of 40.1 mm, indicating enlargement from the aortic root to ascending aorta. Preoperative transesophageal echocardiography (TEE) revealed that the main cause of AR was suspected to be the right coronary cusp prolapse (RCC). Intraoperative findings showed that the tricuspid aortic valve had no limitation of motion, but the RCC was subjected to central bending and prolapsed. The leaflet bend was thickened and shortened causing AR (type II). The geometric height (gH) of RCC was short at 14 mm, while the other valve cusps were 20 mm. An augmentation of RCC was performed using autologous pericardium, followed by a Florida sleeve procedure performed using 26-mm Gelweave Valsalva™ grafts. The gH of RCC after augmentation was 23 mm, and the effective height was adjusted to 10 mm by central plication, showing no AR by TEE. Postoperative MDCT revealed AVJ of 22.2 mm, Valsalva sinus of 30.9 mm, and STJ of 21.9 mm. Therefore, the Florida sleeve procedure provided a reduction that preserved the geometry of the aortic root, including AVJ and STJ, as intended.

Florida sleeve procedure is a reliable and simple method for ensuring uniform aortic root geometry. A favorable outcome was obtained using the Florida sleeve procedure and augmentation with autologous pericardium in a patient with type II AR and aortic root enlargement.