Ann Thorac Surg 2001;71:1048-1049
© 2001 The Society of Thoracic Surgeons
How to do it
Complex reconstruction of the aortic and mitral annuli: a simplification
Anthony L. Picone, MDa,
Shawn Terry, MDa
a Department of Surgery, University Hospital, Syracuse, New York, USA
Accepted for publication August 17, 2000.
Address reprint requests to Dr Picone, Department of Surgery, University Hospital, 750 E Adams St, Suite 8702, Syracuse, NY 13210
e-mail: piconea{at}upstate.edu
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Abstract
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Simultaneous reconstruction of the aortic and mitral annuli is a useful but complex procedure. Implantation of a bovine pericardial gusset can be facilitated by ex vivo attachment to the sewing ring of the mitral valve prosthesis.
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Introduction
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We recently have had to reconstruct the aortic and mitral valve annuli in 2 patients, 1 with Shone’s complex [1] and 1 with endocarditis. Both patients required bivalvular replacement and complex reconstruction of the aortic-mitral annuli at their confluence. We employed a technique previously described by David and Feindel [2] but have modified the preparation of the mitral valve prosthesis and gusset.
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Technique
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Approach to both the aortic and mitral valves is accomplished by extending the standard curvilinear aortotomy into the left-noncoronary commissure and through the aortic annulus. Simultaneously, the anterior mitral annulus is divided while opening the dome of the left atrium (superior approach) (Step 1, Fig 1a). After excision of the aortic valve and the anterior leaflet of the mitral valve, the aortic and mitral annuli may be expanded at their confluence (Step 2, Fig 1b).
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Fig 1. (a–f) Steps 1–6, respectively. (A = limb A; AL = anterior leaflet; Ao = aorta; B = limb B; L = left coronary cusp; LA = left atrium; NC = non-coronary cusp; PL = posterior leaflet; R = right coronary cusp; RA = right atrium.)
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Reconstruction of the created mitral annular defect, closure of the left atriotomy, and enlargement of the aortic annulus is accomplished using a double gusset of bovine pericardium as described by David and colleagues [3]. In order to estimate the dimension of the gusset base, an appropriate sizer is placed in the mitral annulus and the circumferential distance necessary to complete the neo-annulus is estimated (Step 3, Fig 1c). The double gusset is then created from a folded piece of bovine pericardium with the length of the fold or base trimmed 4 to 8 mm longer then the measured mitral annular defect. To facilitate attachment of the bovine pericardium gusset to the prosthetic mitral valve, the folded base is first sewn to the prosthetic sewing ring with a running 4-0 Prolene (Ethicon, Somerville, NJ) suture prior to implantation (Step 4, Fig 1d).
After implantation of the mitral prosthesis, extended lengths of Prolene suture left at each end of the attached trimmed gusset facilitate suturing of the gusset to the aortic annulus and root (limb A) and closure of the left atriotomy (limb B) (Step 5, Fig 1e). Finally, an appropriately sized aortic prosthesis is inserted into the enlarged aortic annulus and the aortotomy closed for completion of the repair (Step 6, Fig 1f).
Aortic cross-clamp and bypass times averaged 216 minutes and 267.5 minutes, respectively. However, both patients immediately separated from cardiopulmonary bypass. Intraoperative transesophageal echocardiography and early postoperative transthoracic echocardiography revealed competent mitral and aortic prosthetic valve function with no paravalvular leaks. Postbypass bleeding was minimal and did not require reinstitution of bypass at any time.
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Comment
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The technique of sewing supporting material to a valve prosthesis prior to implantation has been described [4]. Although still a complex procedure, ex vivo attachment of the gusset to the mitral valve prosthesis allows a degree of simplification and excellent hemostasis. Conversely, attachment of the gusset after implantation of the mitral prosthesis can be technically difficult with less than ideal exposure. An important aspect in the present setting is to estimate the dimension of the base of the gusset necessary by sizing the new mitral annulus. The annulus must not be oversized, as a large mitral prosthesis will tend to obstruct the ventricular outflow tract. A maximum of a one or two size increase in the mitral annulus appears appropriate. Similarly, the width of the portion of the gusset used to reconstruct the aortic outflow and annulus will allow a one or two size increase in the aortic valve prosthesis.
The extended suture at both ends of the gusset-prosthesis suture line allows hemostatic closure of the aortic subvalvular outflow region and dome of the left atrium. Bleeding in this region can be extremely troublesome. Finally, we concur with others [5] that bovine pericardium handles well, while being durable and hemostatic.
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References
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Terry S.M., Picone A.L., Brandt B., III Reconstruction of the mitral and aortic annuli for advanced management of the Shone complex. J Heart Valve Dis 1999;8:343-345.[Medline]
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David T.E., Feindel C.M. Reconstruction of the mitral annulus. Circulation 1987;76(Suppl):III102.
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David T.E., Feindel C.M., Ropchan G.V. Reconstruction of the left ventricle with autologous pericardium. J Thorac Cardiovasc Surg 1987;94:710-714.[Abstract]
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Harken D.E., Soroff H.S., Taylor W.J., Lefemine A.A., Gupta S.K., Lunzer S. Partial and complete prostheses in aortic insufficiency. J Thorac Cardiovasc Surg 1960;40:744-761.
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David T.E., Feindel C.M., Armstrong S., Zhao S. Reconstruction of the mitral annulus. J Thorac Cardiovasc Surg 1995;110:1323-1332.[Abstract/Free Full Text]
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Abstract
Introduction
