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Ann Thorac Surg 2000;69:1511-1514
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Apicoaortic conduit for left ventricular outflow tract obstruction: revisited

^a Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas, USA

Address reprint requests to Dr Cooley, Texas Heart Institute, PO Box 20345, MC 3-258, Houston, TX 77225-0345
e-mail: dcooley{at}heart.thi.tmc.edu

	Abstract

Top Abstract Introduction Surgical technique Results Comment References

 
Background. We have used a variety of techniques to correct left ventricular outflow tract obstructions, including, in the past, placement of an apicoaortic valved conduit to bypass the outflow tract. Because the operation was technically difficult, it had fallen into disuse. Recently, we used a simplified transthoracic approach to implant apicoaortic conduits in 7 patients with complex lesions of the left ventricular outflow tract.

Methods. The thoracic cavity was entered through the fifth intercostal space in all 7 patients. The distal end of the valve-containing conduit was attached to the aorta with continuous 3-0 or 4-0 polypropylene sutures after incising the pleura over the distal descending aorta. The pericardium was opened to expose the left ventricular apex, which was cored so that the proximal end of the conduit could be inserted into the left ventricular cavity.

Results. Five of the patients recovered completely. The 2 patients who died had severe heart disease and multiple comorbidities.

Conclusions. The transthoracic approach gives direct access to the descending aorta and avoids a redo sternotomy. The technique, which is simple to perform, does not compromise major coronary arteries, the conduction system, or other valves; and may be useful in patients who are not good candidates for other, more conventional procedures.

	Introduction

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Surgical correction of left ventricular outflow tract obstruction usually consists of repair or replacement of the aortic valve or excision of fibrous or muscular elements located in the subannular region. More radical repairs include either patch grafting, which requires a posterior annular incision, or the Rastan-Konno technique [1, 2], which requires an anterior septal incision. The outflow tract can also be bypassed with an apicoaortic valve-containing conduit, which is a less conventional approach to the problem. Although we have previously used this technique, the operation was technically difficult, and, as a result, had fallen into disuse. Recently, however, we used a simplified transthoracic approach to implant apicoaortic conduits in 7 patients with complex lesions of the left ventricular outflow tract not easily amenable to other techniques.

	Surgical technique

Top Abstract Introduction Surgical technique Results Comment References

 
Anesthesia was induced and intubation was done in preparation for collapse of the left lung upon entering the pleural cavity. All 7 patients were placed in the right lateral decubitus position in preparation for the transthoracic incision. The left groin was exposed for subsequent cannulation of the femoral vessels for cardiopulmonary bypass. The thoracic cavity was entered through the fifth intercostal space. Then, the left lung was deflated and retracted cephalad. The pleura was incised over the distal descending aorta, after which a partial occluding clamp was applied. The distal end of the valve-containing conduit was attached to the aorta with continuous 3-0 or 4-0 polypropylene suture (Fig 1A). The conduit was then clamped and the partial occluding clamp removed.

View larger version (58K): [in this window] [in a new window]   Fig 1. (A) With the patient in the right lateral decubitus position, the thorax is entered through the fifth intercostal space (inset). The descending aorta is partially occluded and the valved conduit anastomosed with a continuous 3-0 or 4-0 polypropylene suture. (B) During cardiopulmonary bypass, the rigid prosthesis is attached to the apex of the left ventricle with interrupted, pledgeted mattress and continuous sutures. Induced ventricular fibrillation is used to facilitate the ventricular attachment. Temporary occluding clamps are used on the grafts during anastomoses. (C) After tailoring, the prostheses are connected with a continuous suture. Air is evacuated and cardiac function resumes. Ventricular countershock may be necessary to restore sinus rhythm.

Prosthesis
The apicoaortic conduits used in these patients comprise two parts. The distal portion consisted of a woven Dacron tube that contained a Bjork-Shiley tilting disc valve (first 3 patients). More recently (4 patients), we have used a St. Jude valve-containing conduit (Minneapolis, MN). We changed to St. Jude when we depleted our stock of Bjork-Shiley conduits. The apical prosthesis is a rigid, right-angled connector with an attached sewing ring; its internal surface is made of woven fabric (Medtronic Hancock Left Ventricular Connector; Medtronic Inc, Minneapolis, MN).

	Results

Top Abstract Introduction Surgical technique Results Comment References

 
Seven patients underwent apicoaortic conduit implantation for various etiologies using the simplified transthoracic approach (Table 1). Five patients survived. The first patient who died had highly symptomatic chronic pulmonary congestion and had undergone two previous coronary artery bypass procedures: a quadruple in 1988 and a triple in 1994. Given his surgical history, a repeat sternotomy would have been technically tedious. After the conduit implantation, he developed heparin-induced thrombocytopenia, which required exploratory thoracotomy for hemostasis. Unfortunately, his respiratory insufficiency recurred, and he died 2 weeks after his operation.

The remaining 5 patients recovered completely.

	Comment

Top Abstract Introduction Surgical technique Results Comment References

 
The simpler transthoracic incision allowed us to use the apicoaortic technique of conduit placement in 7 patients whose severe disease kept them from being acceptable candidates for other, more conventional procedures. Use of an apicoaortic conduit to relieve left ventricular outflow obstruction has an impressive history [4–6]. Four years after our first experience with implanting apicoaortic conduits [7], we described 14 patients whose flow gradients decreased from an average of 100 mm Hg before surgery to 22 mm Hg after surgery; in this series, we found that 36% of left ventricular outflow was being ejected through the conduit [8]. In another 4-year follow-up report of 27 patients [3], gradients decreased by 85%. In 1986, Sweeney and associates [9] reported a 78% survival rate after 5 years in a series of 38 of our patients.

Although our initial experiences proved the feasibility of the double-outlet left ventricle, the operation was technically difficult; as a result, the technique had fallen into disuse. In some patients, the porcine valve deteriorated and had to be replaced. In the early cases, most of the aortic anastomoses were made to the supraceliac abdominal aorta or, in a few cases, to the ascending aorta. In several patients, saphenous vein bypass grafts were used as conduits to the coronary arteries. The surgical approach in all of these early cases was through a sternotomy incision.

For the 7 patients in this report, the surgical approach was made through a left lateral thoracotomy, obviating the need for repeat sternotomy. The transthoracic approach gives direct access to the descending aorta, avoids a redo sternotomy, and could possibly be performed without cardiopulmonary bypass. Using a lateral approach facilitated the procedure; the incision seemed to be better tolerated by the patients. Although the conduit is still commercially available, we initially used prostheses that had been in our inventory for more than 5 years. A surgeon could fabricate the valved portion of the conduit with the valve of his choice; however, the commercial, rigid apical connector should be used. The choice of a biologic versus a mechanical valve depends upon the usual considerations: selecting an appropriate device to suit the patient’s needs.

As the use of left ventricular assist devices becomes more widespread, this experience with a transthoracic incision may become of practical importance. Meanwhile, the described technique provides a practical surgical alternative for patients with unusual pathologic conditions in the left ventricular outflow tract. The technique is simple to perform and does not compromise major coronary arteries, the conduction system, or other valves. It is useful in cases of porcelain aorta, when aortic cross-clamping may be associated with a high risk of dissection, hemorrhage, or embolization. This approach may also be considered for patients who have undergone or developed complications, such as infection or false aneurysm formation, from previous surgery.

	References

Top Abstract Introduction Surgical technique Results Comment References

 

1. Rastan H., Koncz J. Aortoventriculoplasty. J Thorac Cardiovasc Surg 1976;71:920-927.[Abstract]
2. Konno S., Imai Y., Iida 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;70:909-917.[Abstract]
3. Norman J.C., Nihill M.R., Cooley D.A. Valved apicoaortic composite conduits for left ventricular outflow tract obstruction. Am J Cardiol 1980;45:1265-1271.[Medline]
4. Carrel A. On the experimental surgery of the thoracic aorta and the heart. Ann Surg 1910;52:83-95.[Medline]
5. Bailey C.P., Glover R.P., O’Neill T.H.E., Ramirez H.P.R. Experiences with the experimental surgical relief of aortic stenosis. J Thorac Surg 1950;20:516-541.
6. Sarnoff S.J., Donovan T.J., Case R.B. The surgical relief of aortic stenosis by means of apical aortic valvular anastomoses. Circulation 1955;11:564-574.[Medline]
7. Cooley D.A., Norman J.C., Reul G.J., Jr, Kidd J.N., Nihill M.R. Surgical treatment of left ventricular outflow obstruction with apicoaortic valved conduit. Surgery 1976;80:674-680.[Medline]
8. Nihill M.R., Cooley D.A., Norman J.C., Hallman G.L., McNamara D.G. Hemodynamic observations in patients with left ventricle to aorta conduit. Am J Cardiol 1980;45:573-582.[Medline]
9. Sweeney M.S., Walker W.E., Cooley D.A., Reul G.J. Apicoaortic conduits for complex left ventricular outflow obstruction. Ann Thorac Surg 1986;42:609-611.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Denton A. Cooley Ruben M. Lopez Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cooley, D. A. Articles by Absi, T. S. Search for Related Content PubMed PubMed Citation Articles by Cooley, D. A. Articles by Absi, T. S.