Ann Thorac Surg 1999;67:1176-1177
© 1999 The Society of Thoracic Surgeons
How To Do It
Coronary reimplantation in aortic root replacement: a method to avoid tension
Stephen Westaby, FRCSa,
Takahiro Katsumata, MD, PhDa,
Giuseppe Vaccari, MDa
a Oxford Heart Centre, The John Radcliffe Hospital, Oxford, United Kingdom
Accepted for publication September 15, 1998.
Address reprint requests to Mr Westaby, Department of Cardiac Surgery, Oxford Heart Centre, The John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, England
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Abstract
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We describe a technique to relieve tension on the reimplanted right coronary button during aortic root replacement. A hood is fashioned from autogenous aorta or pericardium to provide a funnel inflow to the coronary ostium. The technique can be used either electively or as a rescue maneuver in the event of right ventricular ischemia.
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Introduction
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Aortic root replacement is now done by complete excision of the native coronary ostia and reimplantation into a valved conduit [1]. This procedure usually can be accomplished without tension, although some surgeons prefer to use an interposition conduit occasionally [2–4]. We occasionally encounter difficulty in direct reimplantation of the right coronary artery in infants or children who have root replacement or the Ross procedure. This difficulty occurs when there is size discrepancy between the native aorta and the new conduit. In such cases we used a simple hood of native aorta or pericardium to prevent kinking of the reimplanted vessels.
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Technique
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Tension or angulation on the right coronary artery might be apparent during the surgical procedure or when the heart distends at the end of cardiopulmonary bypass (Fig 1). Our routine method is to reimplant the left coronary button first then perform the anastomosis between the distal aorta and the conduit. The position of right coronary artery implantation is then determined with the valved conduit distended by blood. At this time we determine whether tension is likely. The proximal part of the right coronary artery can be mobilized from the atrioventricular groove, but if this does not relieve tension we fashion a hood of excised native aorta or autogenous pericardium. The width of the hood is two-thirds the circumference of the coronary button. The length must be sufficient to allow about a 45-degree angle of the coronary button with the aorta. This hood is then joined to the reimplanted coronary as shown in Figure 2.
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Fig 1. Kinking (arrow) of the reimplanted right coronary artery after homograft replacement of the aortic root.
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Fig 2. (A) A semicircular hood is fashioned from a piece of autogenous pericardium. (P = pericardial hood.) (B) The pericardial hood augments the size of the reimplanted coronary button and relieves tension. (P = pericardial hood.)
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The coronary anastomosis is started by joining the inferior lip of the coronary button to the conduit, then continuing the suture line between the hood and the conduit. The length of the hood is then trimmed appropriately to provide a funnel into the reimplanted right coronary. Although we have not used this method for the left coronary artery, we believe it to be similarly applicable.
In the event of right ventricular ischemia from a mechanical cause (not air) after an otherwise uneventful aortic root replacement, we recommence cardiopulmonary bypass, cross-clamp the aorta, and perform the hood procedure.
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Comment
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We first used the hood method to relieve tension on a right coronary button in a 2-year-old boy who presented for reoperation with an ascending aortic and arch aneurysm after neonatal repair of aorto-left ventricular tunnel (Fig 3). Size discrepancy mitigated against the Ross procedure, which was reserved for his next operation. Scarring and distortion from the first operation caused difficulty with reimplantation during root and arch replacement with a 17-mm aortic homograft. In this case the hood maneuver with autogenous pericardium was undertaken as a rescue procedure for right ventricular ischemia. The pericardial hood augmented the size of the reimplanted coronary button and will facilitate mobilization of the coronary artery from the calcified homograft at the next operation. The patient is asymptomatic (New York Heart Association class I) 1 year after the operation.
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Fig 3. Aortography shows an ascending aortic and arch aneurysm (38 mm of the maximum diameter) with nondisplaced coronary ostia.
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Although the use of an interposition vascular graft is technically feasible in infants and children, the risk of thrombosis and absence of growth render the hood method preferable. We now prefer this to the Cabrol method in all age groups.
Although we do not expect pericardium to become aneurysmal, the use of a patient’s own aortic wall rules out this possibility. There have been reports of calcification in autogenous pericardium used to enlarge an aortic root [5, 6], but this does not contraindicate the operation described.
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References
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Kouchoukos N.T., Karp R.B., Blackstone E.H., Kirklin J.W., Pacifico A.D., Zorn G.L. Replacement of the ascending aorta and aortic valve with a composite graft. Results in 86 patients. Ann Surg 1980;192:403-413.[Medline]
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Cabrol C., Pavie A., Mesnildrey P., et al. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries. J Thorac Cardiovasc Surg 1986;91:17-25.[Abstract]
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Piehler J.M., Pluth J.R. Replacement of the ascending aorta and aortic valve with a composite graft in patients with nondisplaced coronary ostia. Ann Thorac Surg 1982;33:406-409.[Abstract/Free Full Text]
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Katsumata T., Ihashi K. An alternative technique for coronary reattachment in aortic root replacement. The ‘shell’ button technique. J Jpn Assn Thorac Surg 1996;44:1759-1762.
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Piehler J.M., Danielson G.K., Pluth J.R., et al. Enlargement of the aortic root or annulus with autogenous pericardial patch during aortic valve replacement. J Thorac Cardiovasc Surg 1983;86:350-358.[Abstract]
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El Oakley R.M., Grotte G.J. Severe calcification of a parietal pericardial patch used in an aortic root enlargement: case report. J Thorac Cardiovasc Surg 1994;107:634-635.[Free Full Text]
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Abstract
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