Bibliographic record
Abstract
Central MessageSuccessful innovation exemplifies an understanding of 3D anatomy. This application is a novel means to implant larger valves, but it comes with a concern of coronary movement that must be recognized.See Article page 13. Successful innovation exemplifies an understanding of 3D anatomy. This application is a novel means to implant larger valves, but it comes with a concern of coronary movement that must be recognized. See Article page 13. In this technical treatise, Yang1Yang B. A novel simple technique to enlarge the aortic annulus by two valve sizes.J Thorac Cardiovasc Surg Tech. 2021; 5: 13-16Google Scholar has provided us a detailed description of his novel approach to manage patients with small aortic roots undergoing aortic valve replacement. Whereas some surgeons dismiss the concerns of implanting small valves in this situation with the potential of patient–prosthesis mismatch, most of us avoid this complication by using some form of root enlargement, such as Nicks or Manouguian procedures or by consideration of a modified Bentall as an alternative. Yang has clearly described the sequential steps to support this approach such that a practicing, experienced surgeon could attempt this safely. It is not clear to this reviewer that the annulus is actually enlarged with this approach. The proposed incision is an inverted “T,” and the patch is essentially tailored such that its width (after suturing) is the same measure as the horizontal portion of the “T” shown in the central picture. In the Nicks procedure, the incision and subsequent placement of the patch actually increases this horizontal measure, explaining the mechanism for true enlargement. Regardless, Yang's strategy appears to work; I suspect that it allows the operator to safely tilt the valve when suturing in the region of the commissure between the left and the noncoronary. The advantage of the approach is that it allows insertion of a larger valve without compromise of the left coronary ostium, arguably by modest tilting of the valve. This alignment is enabled by the mandatory 90-degree clockwise rotation of the left coronary ostium. The surgeon must be aware of the arc of rotation of the coronary and recognize the potential risk, particularly if there is some degree of calcification of the left main, in which case rotation without sufficient mobilization could be accompanied by lumen compromise. As more and more straightforward aortic valves with normal preoperative annulus get gobbled up by the transaortic valve replacement train, the relative proportion of patients with small annuli will continue to increase and we will see more of these patients. Yang's strategy offers another arrow to our strategic quiver. Its use should be cautiously encouraged with the caveat that we must fully understand the root and coronary manipulations that accompany this technique. I hope to see collaboration with his radiology colleagues to better delineate the anatomic changes that ensue from this strategy, particularly if any of these patients go down the path of valve-in-valve transaortic valve replacement procedures in the future. A novel simple technique to enlarge the aortic annulus by two valve sizesJTCVS TechniquesVol. 5PreviewThe current techniques of aortic root enlargement used by adult cardiac surgeons are the Nicks1 and Manouguian procedures.2 The Nicks procedure generally increases aortic annulus by one valve size.1 The Manouguian requires incising the mitral valve (MV) anterior leaflet and left atrium (LA), with risk of mitral regurgitation.3 Reported herein is a new surgical technique to enlarge the aortic annulus by 2 valve sizes without violating the LA or MV. Full-Text PDF Open Access
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.007 | 0.076 |
| Meta-epidemiology (narrow) | 0.002 | 0.002 |
| Meta-epidemiology (broad) | 0.002 | 0.002 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.006 | 0.006 |
| Scholarly communication | 0.004 | 0.009 |
| Open science | 0.006 | 0.003 |
| Research integrity | 0.070 | 0.074 |
| Insufficient payload (model declined to judge) | 0.018 | 0.014 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".