Ann Thorac Surg 1997;63:261-263
© 1997 The Society of Thoracic Surgeons
How To Do It
Two-Directional Aortic Annular Enlargement for Aortic Valve Replacement in the Small Aortic Annulus
Masaki Otaki, MD,
Hidetaka Oku, MD,
Susumu Nakamoto, MD,
Hitoshi Kitayama, MD,
Masao Ueda, MD,
Terufumi Matsumoto, MD
Department of Cardiac Surgery, Kinki University School of Medicine, Osaka-Sayama-shi, Osaka, Japan
Accepted for publication September 13, 1996.
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Abstract
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We have encountered 3 patients with a small aortic annulus for whom the conventional posterior enlargement alone was not extensive enough to implant an artificial valve of acceptable size. Therefore, we performed two-directional enlargement, which is a combination of posterior and anterior enlargement. First, the posterior enlargement was done, and then an additional aortotomy was made anteriorly and extended to the ventricular septum. The aortic annulus was enlarged by 68% after the two-directional enlargement. At a follow-up of 31 months, the patients' functional status was New York Heart Association class I.
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Introduction
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In patients with a small aortic annulus, the decision to use a small prosthesis (less than 21 mm in diameter) or to enlarge the aortic annulus remains controversial. Recently, reports on the St. Jude Medical prosthesis (19 mm) have suggested its usefulness in a small aortic root. However, Kratz and associates [1] have described that in patients with a body surface area greater than 1.7 m2, the 19-mm St. Jude valve should be avoided and an aortic annulus-enlarging procedure must be considered.
This study reports two-directional annular enlargement in 3 patients with aortic annuli of less than 19 mm in diameter (11, 16, and 18 mm, respectively). In such patients, not only is aortic valve replacement (AVR) using a 19-mm prosthetic valve with a standard technique impossible, but also conventional posterior enlargement alone is not extensive enough for implanting a prosthetic valve of an acceptable size.
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Patients, Surgical Techniques, and Results
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This report describes 3 patients who underwent AVR with the two-directional aortic annular enlarging procedure between January 1992 and July 1995 at the Department of Cardiac Surgery, Kinki University Hospital, Osaka, Japan. Table 1
summarizes the patients' clinical data. There were 2 male patients and 1 female patient. In our series, operations were performed with cardiopulmonary bypass, hypothermia (27°C), intermittent cardioplegia, and local cooling. Figure 1 demonstrates the complete preparation of the surgical procedure. Arteriotomy was made obliquely toward the noncoronary sinus. The aortic annulus was measured with dilators after removal of the aortic valve.
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Fig 1. . The aortotomy was made obliquely toward the noncoronary sinus. After the aortic annulus was measured with dilators after removal of the aortic valve, posterior enlargement was performed according to the Nicks procedure (patients 1 and 2: isolated aortic valve replacement) or the Manouguian procedure (patient 3: aortic and mitral valve replacements) and then an additional anterior enlargement was made just to the commissure between the left and the right coronary cusps. Reconstruction of the annulus and repair of the aortotomy were obtained with a bifurcated Dacron patch.
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The original annular diameter was 11, 16, and 18 mm, respectively, and consequently AVR using even a 19-mm prosthetic valve was virtually impossible. Therefore, an annular-enlarging procedure was performed to insert a prosthetic valve with an adequate size. First, the aortic annulus was enlarged via posterior enlargement according to the Nicks procedure [2] (patients 1 and 2: isolated AVR) or the Manouguian procedure [3] (patient 3: aortic and mitral replacements). After this enlargement, the annulus increased to 15 mm (36% increase), 19 mm (19% increase), and 21 mm (17% increase), respectively, but these diameters were not extensive enough to implant appropriate prosthetic valves (Tables 2, 3). To obtain a larger orifice, we made an additional anterior aortotomy and extended it to the ventricular septum through the commissure between the left and right coronary cusps; it did not reach the ventricular septum as in the Konno procedure. The combination of posterior and anterior enlargements increased the diameter of the aortic annulus to 23 mm (109% increase), 24 mm (50% increase), and 26 mm (44% increase), respectively (see Tables 2, 3). Regarding the implantable prosthetic valve, its mean size was 14 mm before enlargement, then 17 mm after posterior enlargement, and finally 23 mm after the two-directional enlargement.
All patients underwent AVR with a St. Jude Medical valve of an acceptable size (23-mm valve). Reconstruction of the aortic annulus and ventricular septum was done using a bifurcated Dacron patch, and the aortotomy was repaired. These procedures were accomplished in all patients without technical problems, such as bleeding or injuries of the coronary artery. During a mean follow-up of 31 months, all patients were in good functional status, ie, New York Heart Association class I.
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Comment
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In patients with a small aortic annulus, it is still controversial whether to use a small prosthetic valve (equal to or less than 21 mm in diameter) or to enlarge the aortic annulus. However, when the aortic annulus is extremely small and valve replacement cannot be accomplished even with a 19-mm prosthetic valve employing the standard technique, an annulus-enlarging procedure should be considered.
From a clinical perspective, several annulus-enlarging procedures have been reported for AVR in patients with a small aortic annulus. Konno and associates [4] reported enlargement of the left ventricular outflow tract and the aortic annulus by extensive ventriculotomy. This procedure requires opening and enlarging of the right ventricular outflow tract and repair of the subsequent ventricular septal defect. Manouguian and Seybold-Epting [3] reported their surgical experience in patch enlargement of the narrow aortic annulus performed by making a posterior incision toward the anterior mitral annulus. Nicks and colleagues [2] proposed enlargement of the aortic annulus by extending the incision to the noncoronary sinus through the aortic annulus.
However, the long-term results of the conventional annular-enlarging procedures are still controversial. The potential risk of mitral dysfunction associated with Manouguian and Seybold-Epting's procedure, ie, incision of the mitral annulus and patch repair of the intact mitral leaflet, has not been clarified. Injuries of the major septal coronary arteries and conduction systems with the Konno procedure are major disadvantages. The Nicks procedure is considered safer in patients with isolated AVR, although enlargement by this method in our experiences is less extensive than by the Manouguian or Konno procedure. Using the two-directional approach in patients with isolated AVR in this study, the Nicks procedure could be supplemented with an anterior enlargement, and more extensive enlargement could be obtained. By our technique, we could avoid incision into the mitral annulus (a step of the Manouguian procedure) and extensive ventriculotomy (a step of the Konno procedure), both of which may produce postoperative complications.
Bilateral enlargement of the aortic annulus as presented in this article was originally applied to younger children with congenital supraannular aortic stenosis by Yamaguchi and associates [5]. Their operation is a combination of the Nicks procedure with an additional aortotomy incision to the right and left coronary commissures. Our procedure is a combination of the posterior procedure with an additional aortoventriculotomy through the commissure between the right and left cusps. The mean diameter of the aortic annulus was 15 mm originally, 18 mm after the posterior enlargement (24% increase), and then 24 mm after the additional anterior enlargement (68% increase). Yamaguchi and associates [5] reported that the enlarged diameter after two-directional approach in infant patients is larger than that with the Nicks procedure (16% increase) [6] or the Manouguian procedure (22% increase) [7]. In addition, a supplemental anterior enlargement can be accomplished without technical problems, even after the conventional posterior enlargement is proved to be unsuccessful.
When the posterior enlargement alone is performed, the annulus is enlarged posteriorly and the prosthetic valve is anchored in a posteriorly deviated position. Yet, the prosthetic valve can be implanted in a more central position and more physiologic flow can be expected when the two-directional enlargement is performed.
In the present study, we can emphasize the following advantages of the two-directional enlargement. First, in patients who need AVR in whom satisfactory enlargement of the small aortic annulus cannot be achieved by the posterior procedure alone, the anterior enlargement can be done after the posterior enlargement. Second, the two-directional enlargement provides a better opportunity to implant a prosthetic valve of an acceptable size than the posterior enlargement alone in adults, and allows implantation of adult-sized valves in older children requiring AVR. Third, the two-directional enlargement will provide a more central position to the prosthetic valve, and consequently more luminal and physiologic flow may be expected. Finally, the two-directional approach may provide less incidence of potential risks, such as mitral dysfunction, coronary injuries, and conduction disturbances.
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Footnotes
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Address reprint requests to Dr Otaki, Department of Cardiac Surgery, Kinki University School of Medicine, 377-2, Ohno-Higashi, Osaka-Sayama-shi, Osaka 589, Japan.
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References
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- Kratz JM, Sade RM, Crawford FA Jr, Crumbley AJ, Stroud MR. The risk of small St. Jude aortic valve prostheses. Ann Thorac Surg 1994;57:1114–9.[Abstract/Free Full Text]
- Nicks R, Cartmill T, Bernstein L. Hypoplasia of the aortic root. Thorax 1970;25:339–46.[Abstract/Free Full Text]
- Manouguian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. J Thorac Cardiovasc Surg 1979;78:402–12.[Abstract]
- Konno S, Imai Y, Lida Y, Nakajima M, Tatsuno K. A new method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia of the aortic valve ring. J Thorac Cardiovasc Surg 1975;70:909–17.[Abstract]
- Yamaguchi M, Ohashi H, Imai M, Oshima Y, Hosokawa Y. Bilateral enlargement of the aortic valve ring for valve replacement in children. New operative technique. J Thorac Cardiovasc Surg 1991;102:202–6.[Abstract]
- Mori T, Kawashima Y, Kitamura S, et al. Results of aortic valve replacement in patients with a narrow aortic annulus: effects of enlargement of the aortic annulus. Ann Thorac Surg 1981;31:111–8.[Abstract/Free Full Text]
- Pugliese P, Bernabei M, Santi C, Pasque A, Eufrate S. Posterior enlargement of the small annulus during aortic valve replacement versus implantation of a small prosthesis. Ann Thorac Surg 1984;38:31–6.[Abstract/Free Full Text]
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Abstract
Introduction
