Ann Thorac Surg 1997;63:548-550
© 1997 The Society of Thoracic Surgeons
Case Report
Commissurotomy and Bileaflet Pericardial Augmentation-Resuspension for Bicuspid Aortic Valve Stenosis
M. Adebambo Kadri, MD,
Hagop Hovaguimian, MD,
Albert Starr, MD
Albert Starr Academic Center for Cardiac Surgery, St. Vincent Heart Institute, Portland, Oregon
Accepted for publication September 30, 1996.
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Abstract
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We describe a valve reconstruction technique for congenital bicuspid aortic valve stenosis employing a commissurotomy, resection of raphe between conjoint leaflets, and bileaflet augmentation-resuspension using a triangular strip of glutaraldehyde-preserved autologous pericardium. This maneuver relieves aortic valve stenosis, preserves the native valve leaflets, reproduces the natural trileaflet scalloping of the aortic valve annulus, and improves cusp coaptation.
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Introduction
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Complete commissurotomy for congenital bicuspid aortic valve stenosis is limited in most patients by lack of support of the individual leaflets. Under these circumstances, massive aortic regurgitation may be induced. Leaving the valve bicuspid may not be satisfactory because of residual stenosis. In such cases, additional leaflet tissue can provide support and allow complete commisssurotomy when the only other alternative would be total valve replacement.
Often, the patient is a young patient or female patient with prospects of future pregnancies. In these patients, the durability of a bioprosthesis is expected to be very limited, and permanent anticoagulation for a mechanical prosthesis can be often difficult and associated with serious complications. These considerations along with encouraging results of valvuloplasties in the atrioventricular positions [1, 2] mandated us to explore alternative surgical approaches for the treatment of aortic valve stenosis.
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Technique
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Cardiopulmonary bypass is established with ascending aortic and right atrial cannulation. The patient is cooled to 26°C. After aortic cross-clamping, a transverse aortotomy is performed and cold blood cardioplegia is infused directly into the coronary ostia. In congenitally bicuspid valves, the most common feature is fusion of two cusps, usually the right and left coronary cusps (Fig 1
). In this arrangement, a rudimentary commissure (raphe) is usually visible and is often the site of leaflet calcification. This commissure is incised right up to the aortic wall (Fig 2). If necessary, the raphe is excised. Because the height of the rudimentary commissure is low, the cusps are shallow and subject to flail if left unsupported. The leaflets are thus resuspended at that commissure after they are first augmented with a triangular patch of glutaraldehyde-preserved autologous pericardium. The pericardial patch is cut in the shape of an isosceles triangle, the base of which is twice the length of the median raphe of the conjoint leaflet and the height of which is the shortfall in the desired height of the fused commissure (see Fig 2). One half of the base of the patch is sewn into the incised edge of the right coronary cusp right up to the aortic wall using continuous 6-0 Cardionyl suture (Péters Laboratoire Pharmacetique, Bobigny, France). The other half is sewn into the incised edge of the left coronary leaflet (Fig 3). The two sides of the triangular patch now become continuations of the free margins of the right and left coronary cusps. In cases where there is partial fusion of either of the other commissures, this is opened up by incising up to the aortic wall. Any thickened portions on any of the leaflets are shaved thin to leave them mobile and flexible. Next the midportion of the patch is attached to the aortic wall at the level of the excised median raphe with three interrupted mattress sutures of 6-0 Cardionyl, one at the middle of the base of the triangular patch, one at its apex, and one in between (see Fig 3). The knots are tied outside the aorta. This maneuver extends the commissure further downstream on the aortic wall to coincide with the other two commissures, thus increasing the depth of the coronary cusps. At the end there is good leaflet support with a wider zone of leaflet coaptation such that aortic obstruction is relieved with no residual regurgitation.
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Fig 1. . (Top) Normal trileaflet aortic valve. (Bottom) Affected bileaflet valve with a rudimentary raphe between the fused left and right leaflets. There is also some fusion at the commissure between the conjoined and the noncoronary leaflets.
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Fig 2. . (Top) The full length (A) of the fused commissure between the right and left cusps has been incised up to the aortic wall. The small fused area between the left and noncoronary cusps has also been opened up. (Center) The new right and left aortic leaflets are shallow and poorly supported due to the the shortfall (H) in the height of the rudimentary commissure. (Bottom) A piece of glutaraldehyde-preserved autologous pericardium has been cut out as an isosceles triangle whose height equals H and base is twice the length of A.
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Fig 3. . (Top) One half of the base of the triangular pericardial patch has been sutured into the cut edge of the right coronary leaflet and the other half into the adjacent left coronary leaflet. The shallow commissure has been resuspended at a normal level with three full-thickness sutures tied outside the aortic wall. (Bottom) The free edges of the right and left leaflets have been augmented by the sides of the triangular patch, allowing a wide zone of leaflet coaptation.
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The aorta is then closed with continuous 4-0 Prolene (Ethicon, Somerville, NJ) suture, and upon removal of the aortic cross-clamp, the heart is tested for absence of aortic regurgitation by estimating the amount of blood coming from the left atrial vent. The absence of aortic regurgitation is confirmed by intraoperative transesophageal echocardiography.
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Comment
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Since the first report [3] in 1960 of the surgical correction of aortic insufficiency associated with ventricular septal defect, several surgical procedures have been employed for the treatment of the diseased aortic valve. Open valvotomy, closed transventricular dilation of the aortic valve, and balloon valvotomy have all been used for the relief of congenital aortic stenosis. However, long-term results are unsatisfactory, with residual valvular stenosis and regurgitation necessitating subsequent valve replacement in most cases [4]. Awareness of the drawbacks of the available valve substitutes, the standardization and universal acceptance of the repair techniques on the atrioventricular valves, and the good results of aortic valvuloplasty in adult rheumatic heart disease has stimulated interest in aortic valve repair in the paediatric age group [4, 5].
We believe that after commissurotomy and excision of the raphe, bileaflet augmentation and resuspension to the aortic wall as described in this report reproduces the natural trileaflet anatomy of the aortic valve, provides depth to the cusps, and allows good coaptation between the leaflets, thus obviating residual regurgitation. The pericardial patch used should be taut enough to prevent prolapse of the leaflets into the ventricular cavity during systole or obstruction of the coronary ostium during diastole. Pretreating the pericardium with glutaraldehyde prevents shrinkage and aneurysmal change by pressure and should avoid these complications.
The question of the long-term durability of the pericardium in this setting should be addressed. The report by Chauvaud and associates [6] concerning the advantages of glutaraldehyde-treated autologous pericardium in the mitral position is encouraging. The present aortic reconstruction technique offers several other potential advantages. The absence of a rigid stent should improve the gradient across the valve, reduce tissue stress, and increase durability. Being stentless and nonantigenic, the glutaraldehyde-treated autologous pericardial patch should be accompanied by a lower risk of thromboembolism and other valve-related morbidity than the standard bioprostheses. Even in the event of future calcification, excision should be easy and the native valve tissue still intact.
A 15-year-old girl who underwent this repair in our institution remains asymptomatic nearly 6 years postoperatively, and 5-year follow-up echocardiography revealed no aortic stenosis, mild to moderate aortic regurgitation, but well-preserved wall motion and systolic function. This technique preserves native valve function and avoids or at least defers aortic valve replacement and might represent a valid alternative especially in children and female patients of child-bearing age.
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Acknowledgments
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We acknowledge the invaluable contributions of Joanie Livermore, the medical artist who prepared the illustrations to this article.
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Footnotes
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Address reprint requests to Dr Kadri, Albert Starr Academic Center for Cardiac Surgery, St. Vincent Heart Institute, 9155 SW Barnes Rd, Suite 240, Portland, OR 97225.
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References
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- Cosgrove DM, Rosenkranz ER, Hendren WG, Bartlett JC, Stewart WJ. Valvuloplasty for aortic insufficiency. J Thorac Cardiovasc Surg 1991;102:571–7.[Abstract]
- Galloway AC, Colvin SB, Bauman FG, et al. Current concepts of mitral valve reconstruction for mitral insufficiency. Circulation 1988;78:1087–98.[Abstract/Free Full Text]
- Starr A, Menashe V, Dotter D. Surgical correction of aortic insufficiency associated with ventricular septal defect. Surg Gynecol Obstet 1960;111:71–6.
- Caspi J, Ilbawi MN, Robertson DA, Piccione W Jr, Monson DO, Najafi H. Extended aortic valvuloplasty for recurrent vavular stenosis and regurgitation in children. J Thorac Cardiovasc Surg 1994;107:1114–20.[Abstract/Free Full Text]
- Duran C, Kumar N, Gometza B, Al Halees Z. Indications and limitations of aortic valve reconstruction. Ann Thorac Surg 1991;52:447–54.[Abstract/Free Full Text]
- Chauvaud S, Jebara V, Chachques JC, et al. Valve extension with glutaraldehyde-preserved autologous pericardium. Results in mitral valve repair. J Thorac Cardiovasc Surg 1991;102:171–8.[Abstract]
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Abstract
Introduction
