Ann Thorac Surg 2000;69:1598-1600
© 2000 The Society of Thoracic Surgeons
How to do it
Aortoventriculoplasty in patients with aortic malposition
Ichiro Kashima, MDa,
Ryo Aeba, MDa,
Toshiyuki Katogi, MDa,
Koji Tsutsumi, MDa,
Shiaki Kawada, MDa
a Division of Cardiovascular Surgery, Keio University, Tokyo, Japan
Address reprint requests to Dr Aeba, Division of Cardiovascular Surgery, Keio University, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan
e-mail: aeba{at}mc.med.keio.ac.jp
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Abstract
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Aortoventriculoplasty was applied successfully for recurrent combined subvalvular and valvular aortic obstruction that developed after intraventricular baffle repair of a cardiac anomaly in 2 patients with associated anterior malposition of the aorta. A single baffle for the left ventricular tunnel was also used for aortic annulus augmentation.
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Introduction
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Aortoventriculoplasty (AVP) is an effective surgical technique for disproportionately or proportionately small aortic and subaortic dimensions in patients with normal aortic position. The anterior annulus incision, which provides exposure for the most extensive augmentation, has been used to achieve satisfactory early and long-term results [1]. We have used the anterior annulus incision in patients with aortic malposition.
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Technique
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Patient 1
A 7-year-old boy presented to our hospital with aortic valvular stenosis, transposition of the great arteries {S, D, D}, a noncommitted ventricular septal defect (VSD), single-origin coronary arteries from the right-facing sinus, and aortic coarctation. Numerous operations had been performed before this consultation. First, his aortic coarctation had been repaired with a subclavian flap aortoplasty at 37 days of age. The Rastelli operation was performed at 47 days of age rather than the arterial switch operation because of the potential risk of kinking of the single-origin coronary arteries. Despite the successful replacement of the intraventricular patch and right ventricular outflow conduit for obstruction at 40 months of age, this patient had a recurrence of left ventricular outflow tract obstruction. Before the AVP, echocardiography and cardiac catheterization (Fig 1) demonstrated an aortic valve annulus of 15 mm (90% of normal) and restricted leaflet motion. In addition, the anterior-posterior width of the subaortic tunnel was 12 mm between the conal septum and the intraventricular baffle. The VSD was 12 mm in diameter. The peak pressure gradient between the left ventricle and the aorta was 70 mm Hg at rest. No aortic regurgitation was noted. At AVP, an anterior longitudinal incision of the aorta was extended into the right ventricular free wall at the proximal end of the previous conduit between the right ventricle and pulmonary artery. After removal of the previous baffle on which peel formation was absent, the VSD was enlarged by myectomy at the left anterior rim (Fig 2, left). A mechanical prosthesis was inserted in the original aortic position (Carbomedics #21 Top Hat, Sulzer Carbomedics Inc, Austin, TX). A single new baffle made from a collagen-impregnated woven Dacron tube graft (Hemashield Microvel double-velour graft, Meadox Medicals, Oakland, NJ) was placed for both the left ventricular outflow tunnel and aortic annulus augmentation. Therefore, the most proximal suture line of the intraventricular baffle shifted to the anterior, caudal, and left (Fig 2, right). The opening of the right ventricular outflow tract was augmented with a separate patch. The postoperative recovery was uneventful. Follow-up echocardiography demonstrated nonobstructed left ventricular outflow tract including the subaortic tunnel and aortic valve.
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Fig 1. (Patient 1.) Preoperative left ventriculogram (transposition of the great arteries, ventricular septal defect, status post-Rastelli operation).
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Fig 2. (Patient 1.) Operative schema (transposition of the great arteries, ventricular septal defect, status post-Rastelli operation). After removal of the previous baffle, the ventricular septal defect was enlarged by myectomy at the left anterior rim (left). A single new baffle was placed for both the left ventricular outflow tunnel and aortic annulus augmentation (right).
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Patient 2
A 14-year-old boy presented with aortic regurgitation and subvalvular and valvular aortic stenosis that developed after repair of a double-outlet right ventricle and subaortic VSD at 18 months of age. Preoperative evaluation revealed an aortic annulus of 21 mm (95% of normal) and a 17 mm subaortic tunnel. There was restricted leaflet motion in both systole and diastole. The peak pressure gradient between the left ventricle and the aorta was 42 mm Hg. Aortography revealed moderate aortic regurgitation. At AVP, a transverse incision was made in the aorta. The aortic valve leaflet, which was badly degenerated, was excised. The aortic valve was rotated clockwise, and the right coronary artery originated from the left but independent of the left coronary ostium, running along the ventriculoaortic groove (Fig 3, left). To prevent transection of or injury to the right coronary artery, a shallow incision was made on the anterior aortic annulus from the inner lumen, rather than a full thickness incision of the annulus. A right ventriculotomy was made parallel to the cardiac long axis, and the previous intraventricular baffle was excised. The VSD was enlarged by myectomy at the conal septum. A new baffle for reconstruction of the left ventricular outflow tract was inserted through the right ventriculotomy. At the most distal end, the baffle was sewn to the inner lumen of the aortic root (Fig 3, right). A mechanical valve (Carbomedics #23) was placed at the original level of the annulus, which was augmented with the same baffle. The right ventriculotomy was augmented with a separate patch using collagen-impregnated woven Dacron (Hemashield Microvel double-velour graft). The postoperative recovery was uneventful. Follow-up echocardiography revealed a nonobstructed left ventricular outflow tract including the subaortic tunnel and aortic valve.
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Fig 3. (Patient 2.) Operative schema (double-outlet right ventricle, subaortic ventricular septal defect, status post-intracardiac repair). A shallow incision was made on the anterior aortic annulus from the inner lumen. The previous intraventricular baffle was excised and the ventricular septal defect was enlarged by myectomy at the conal septum (left). A new baffle for reconstruction of the left ventricular outflow tract was sewn to the inner lumen of the aortic root at the most distal end (right).
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Comment
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The left ventricular outflow tract in patients with aortic malposition can be disproportionately or proportionately narrow at both the subvalvular [2] and valvular levels after repair of heterogeneous cardiac anomalies associated with VSD. In the intraventricular baffle repair, the most distal suture line of the baffle is often either adjacent to or incorporated into the aortic annulus. Surgical relief of obstruction at this location caused by outgrowth of the baffle, fibrous tissue overproliferation, or baffle deformity may require annulus incision. AVP is indicated in these cases.
Our surgical technique is analogous to those in Konno’s AVP for patients with normal aortic position. Both procedures share the same advantages and potential complications. Multilevel obstruction of the left ventricular outflow tract can be managed with a single patch augmentation. Valve prostheses two or three sizes larger than the original annulus size can be accommodated. There is the potential, however, for operative bleeding, right ventricular outflow tract obstruction with suboptimal augmentation, left ventricular dysfunction, and intraventricular conduction injury. In patients with anterior or right aortic malposition, the axis of the left ventricular outflow tunnel and the aorta is curved with a sharper angle than found in patients with normal aortic position. A lack of myocardial or endocardial tissue at the corner of the outflow tract would be advantageous because it is a potential source of residual or recurrent obstruction. One should be attentive to right ventricular outflow reconstruction because the intraventricular baffle necessarily occupies the right ventricular cavity to a greater extent than in Konno’s AVP. A more generous right ventriculotomy may be necessary to avoid this potential complication.
A right coronary artery with abnormal origin from the left side and traversing anterior wall of the aorta is a contraindication or a challenging malformation for AVP. The abnormal right coronary artery requires modification of AVP, including a reimplantation to the right aspect of the aorta [3] and a division followed by bypass grafting. Our technique used in patient 2 is an alternative for this difficult situation. Undue stretch of the right coronary artery is a potential complication, especially when a large valve prosthesis is inserted.
In summary, AVP with an anterior aortic annulus incision was applied successfully for recurrent combined subvalvular and valvular aortic obstruction that developed after intraventricular baffle repair of a cardiac anomaly in 2 patients with associated anterior malposition of the aorta. Intracardiac baffle creation with aortic augmentation using a single baffle is a unique approach to management of left ventricular outflow tract obstruction at multiple levels.
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References
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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]
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Rocchini A.P., Rosenthal A., Castañeda A.R., Keane J.F., Jeresaty R. Subaortic obstruction after the use of an intracardiac baffle to tunnel the left ventricle to the aorta. Circulation 1976;54:957-960.[Abstract/Free Full Text]
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Niinami H., Imai Y., Sawatari K., Terada M., Shinoka T., Sugiyama Y. Konno procedure for congenital aortic stenosis with a single coronary artery from the left coronary sinus. J Cardiac Surg 1992;7:351-356.[Medline]
Accepted for publication December 4, 1999.
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Abstract
Introduction
