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Ann Thorac Surg 2000;69:607-608
© 2000 The Society of Thoracic Surgeons

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Case Reports

Aortic valve repair after arterial switch operation

^a Department of Pediatric and Congenital Heart Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Address reprint requests to Dr Mee, Department of Pediatric and Congenital Heart Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, M41, Cleveland, OH 44195-5066

	Abstract

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A patient with transposition of the great arteries and a ventricular septal defect underwent an arterial switch operation 15 months after pulmonary artery banding. At 12 years of age, severe neoaortic valve regurgitation, due to dilated aortic sinuses and poor leaflet coaptation, developed. Aortic valve repair involved placement of subcommissural sutures, elliptical excision and tailored reduction of two anterior aortic sinuses, with triangular patch expansion of the proximal ascending aorta. A good result was obtained.

	Introduction

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The arterial switch operation (ASO) has become the surgical procedure of choice for transposition of great arteries (TGA) [1]. Aortic valve regurgitation after ASO is more frequent following a two-stage repair with pulmonary artery banding, than after one-stage repair [2]. A patient with neoaortic valve regurgitation after ASO for TGA with a ventricular septal defect (VSD) and prior pulmonary artery banding is described. Aortic valve repair was successfully performed 12 years later.

A neonate with TGA and a VSD was initially palliated by a balloon atrial septostomy at 1 day of life. Pulmonary artery banding was performed at the age of 3 months. An ASO with VSD closure and takedown of the pulmonary artery band was performed at 18 months.

At 12 years of age, the patent was asymptomatic and active in sports, however, echocardiography showed severe aortic valve regurgitation associated with poor cusp coaptation, dilated aortic sinuses and moderate left ventricular dysfunction. The aortic valve annulus was 29 mm, the aortic sinus 37 mm, and the sinotubular junction 25 mm. The left ventricular end diastolic dimension was 56 mm with a 24% shortening fraction. An exercise stress test documented excellent working tolerance, but this was accompanied by a hypertensive systolic blood pressure response and ST segment depression. Coronary angiography revealed that the left anterior descending artery arose from the right coronary artery. At this time, surgical options included aortic valve replacement or repair.

Following redo sternotomy, the heart and great vessels were exposed. The LeCompte maneuver had not been performed. The neoaortic root was enlarged with the sinuses bulging into the right ventricular outflow tract. The great arteries were side-by-side, the original suture line was at the sinotubular junction, and close to the origin of both coronary arteries.

Under cardiopulmonary bypass and cardioplegic arrest, the neoascending aorta was transected. All three leaflets were pliable, with some thickening of the free edges. Three double-pledgetted, horizontal mattress subcommissural sutures were placed to improve leaflet coaptation [3]. From the anterior left and right sinuses, ellipses were excised (Fig 1), and these defects were closed directly, thus reducing the aortic root diameter. A longitudinal incision was then made in the proximal ascending aorta anteriorly, and this was patched with a triangular piece of Dacron (C.R. Bard, Haverhill, PA) graft to produce smooth continuity between aortic sinuses and the proximal ascending aorta. An end-to-end anastomosis was performed with a running suture. After discontinuing cardiopulmonary bypass, intraoperative transesophageal echocardiography showed trivial aortic valve regurgitation. The ascending aorta was now located posterior to the main pulmonary artery. The initial side-by-side appearance was due to rotation of the heart, resulting from the aortic valve regurgitation and volume overload.

View larger version (22K): [in this window] [in a new window]   Fig 1. Technique of aortic valve repair. (A) The great arteries had a side-by-side relationship. (B) Aortotomy was performed at the level of the sinotubular junction and the two anterior neoaortic sinuses were reduced in size. (C) The triangular patch was placed to produce a smooth continuity between the aortic sinuses and the proximal ascending aorta.

	Comment

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Neoaortic valve regurgitation is a recognized late complication of ASO for TGA [2, 4]. Recent series have shown a low incidence of neoaortic valve regurgitation after ASO [4]. Yamaguchi and colleagues have reported that the two-stage ASO had a higher incidence of aortic regurgitation [2]. However, severe aortic valve regurgitation requiring reoperation is uncommon [2, 4]. In this case, a pulmonary artery band had been in place for 15 months. This prolonged period of pulmonary artery banding may have contributed to the neoaortic valve incompetence.

Aortic valve repair has been utilized for congenital and acquired conditions by means of several techniques [3, 5, 6]. Avoiding valve replacement in children is desirable. Aortic valvuloplasty should be performed according to the anatomical changes of the aortic valve apparatus. David and associates have reported aortic valve repair for patients with aneurysm of the ascending aorta and aortic regurgitation [7]. In his series, the ascending aorta, the sinotubular junction, and the sinus of Valsalva were dilated, however the aortic valve leaflets themselves were normal. Replacement of the ascending aorta and the aortic sinuses allowed the valve to be spared. In this case, the ascending aorta and the sinotubular junction were normal, but the sinuses of Valsalva were markedly dilated. The aortic valve leaflets, although thickened, were also normal. At operation, the aortic valve leaflets were preserved and the aortic sinuses were reduced. Aortic sinus reduction was asymmetrical in that two of the three sinuses were addressed, this was however sufficient to allow leaflet coaptation to be achieved after subcommissural suture placement. Studies of the aortic root indicate that the diameter of the aortic sinus is 22% larger than the diameter of the sinotubular junction [8]. In this case, the diameter of the aortic sinus was 48% larger than that of the sinotubular junction, preventing coaptation of the leaflets and resultant aortic valve regurgitation.

The discrepancy between the neoaortic sinus and the ascending aorta may have been present at the time of ASO because the pulmonary artery was banded for a period of 15 months. We constructed a smooth, tapered junction between the aortic sinus and the proximal ascending aorta with a triangular patch to augment the sinotubular junction. In the older patient with TGA, or double-outlet right ventricle with a subpulmonary VSD, there is a large discrepancy in size between the aorta and pulmonary artery. ASO without augmentation of the ascending aorta in such a situation, may result in a significant discrepancy between the aortic sinus and the proximal ascending aorta. Augmentation of the sinotubular junction may improve the geometry of the anastomosis. We have also used subcommissural suture placement with triangular ascending aortic augmentation to repair a 21-month-old patient with simple TGA and a large discrepancy between the aorta and the main pulmonary artery. This patient had no neoaortic regurgitation postoperatively.

The principles of anatomical reconstruction as elucidated by David [7, 8] and Duran [5] have allowed us to preserve the aortic valve in combination with simple augmentation of the sinotubular junction. This technique is easily reproducible, and when combined with subcommissural suture placement, may allow salvage of a native valve. Longer follow-up is required to assess the durability of this technique.

	References

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1. Mee R. Arterial switch operation. In: Stark J., de Leval M., eds. Surgery for congenital heart disease. Philadelphia: WB Saunders, 1994:483-500.
2. Yamaguchi M., Hosokawa Y., Imai Y., et al. Early and midterm results of the arterial switch operation for transposition of the great arteries in Japan. J Thorac Cardiovasc Surg 1990;100:261-269.[Abstract]
3. Fraser C.D., Wang N., Mee R.B.B., et al. Repair of insufficient bicuspid aortic valves. Ann Thorac Surg 1994;58:386-390.[Abstract/Free Full Text]
4. Serraf A., Roux D., Lacour-Gayet F., et al. Reoperation after the arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg 1995;110:892-899.[Abstract/Free Full Text]
5. Duran C., Kumar N., Gometza B., Al Halees Z. Indications and limitations of aortic valve reconstruction. Ann Thorac Surg 1991;52:447-454.[Abstract/Free Full Text]
6. Trusler G.A., Moes C.A.F., Kidd B.S.L. Repair of ventricular septal defect with aortic insufficiency. J Thorac Cardiovasc Surg 1973;66:394-403.[Medline]
7. David T.E., Feindel C.M., Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm. J Thorac Cardiovasc Surg 1995;109:345-352.[Abstract/Free Full Text]
8. Kunzelman K.S., Grande J., David T.E., Cochran R.P., Verrier E.D. Aortic root and valve relationships. J Thorac Cardiovasc Surg 1994;107:162-170.[Abstract/Free Full Text]

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