Ann Thorac Surg 2002;73:725-728
© 2002 The Society of Thoracic Surgeons
Original article: cardiovascular
Complete aortic root replacement in patients with small aortic annulus
Paul P. Urbanski, MD*a
a Herz- und Gefaess-Klinik, Bad Neustadt, Germany
Accepted for publication October 20, 2001.
* Address reprint requests to Dr Urbanski, Herz- und Gefaess-Klinik, Salzburger Leite 1, 97616 Bad Neustadt, Germany
e-mail: urbanski{at}kardiochirurg.de
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Abstract
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Background. We evaluated the effectiveness of our surgical method using a modified self-assembled valved composite graft in patients with a narrow aortic annulus.
Methods. Between August 2000 and May 2001, 10 consecutive patients with a narrow aortic annulus underwent replacement of the aortic valve and the ascending aorta using a valved composite graft with mechanical valve prosthesis. The indication for surgery was aneurysm of the ascending aorta (8 patients) and aortic dissection (2 patients). To avoid valve-patient mismatch, a modified self-assembled valved composite graft was used.
Results. There was no hospital mortality. Echocardiographic evaluation before discharge showed excellent hemodynamics with a mean transvalvular gradient of 10.7 mm Hg (standard deviation ± 2.8 mm Hg).
Conclusions. The described valved composite graft offers very good hemodynamic performance and is a simple and effective device to avoid valve-patient mismatch in patients with a small aortic annulus who need aortic root replacement.
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Introduction
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In all commercially available aortic conduits with a mechanical valve prosthesis the valve is attached to the end of the tubular prosthesis. This design feature has not changed since it was first described by Bentall and De Bono [1] in 1968. These conduits are implanted by passing the sutures through the aortic valve annulus and the suture ring of the valve prosthesis. The inner diameter of the aortic annulus thus determines the size of the conduit. Patients with a narrow annulus require surgical enlargement to allow for a sufficiently large mechanical conduit to be implanted. Moving the valve prosthesis away from the end into the inside of the tube allows implantation of a larger valve with associated hemodynamic benefits.
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Patients and methods
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Between August 2000 and May 2001, 10 consecutive patients requiring aortic root replacement with narrow aortic annulus underwent replacement of the aortic valve and ascending aorta using the valved composite graft with a mechanical valve prosthesis. In this group there were 7 women and 3 men with an aortic annulus diameter of 19 mm and 21 mm, respectively. The mean age was 58.4 years (range, 41 to 68 years). In 8 patients an aneurysm of the ascending aorta with a diameter of more than 5 cm in addition to aortic valve lesion was the indication for operation. In 2 patients there was aortic dissection with concomitant incompetency of the aortic valve requiring surgical intervention. Preoperative patient data are shown in Table 1.
Surgical technique
Replacement of the aortic root was performed using a modified Bentall technique with complete aortic wall resection and excision of the coronary ostia as Carrel buttons. The conduit is assembled during an operation using a collagen-coated woven polyester prosthesis (InterGard; InterVascular, La Ciotat, France) and a mechanical valve prosthesis with a larger geometric orifice area for a given size with improved hemodynamic performance (St. Jude HP, St. Jude Regent; St. Jude Medical Inc, St. Paul, MN or ATS AP; ATS Medical Inc, Minneapolis, MN). After excision of the aortic valve and of the ascending aorta, the outer diameter of the annulus is measured (Fig 1).
In practice this dimension is approximately 3 to 4 mm larger than the inner diameter. A vascular prosthesis of appropriate size is selected along with one of the previously mentioned mechanical valve prostheses. A valve prosthesis is chosen in which the outer diameter measured at the largest dimension of the sewing ring is slightly larger than the inner diameter of the tube. For example, a size 21 St. Jude Regent valve is chosen for a tubular prosthesis with an inner diameter of 22 mm. This results in an interface between the prosthetic graft and mechanical valve that provides firm and elastic seating and prevents perivalvular leakage. The valve is placed into the tubular prosthesis and is attached approximately 3 to 4 mm above its end with a continuous 4-0 polypropylene mattress suture. The conduit is then anastomosed to the annulus with interrupted pledgeted mattress sutures of 3-0 braided polyester by a supraannular technique, passing the sutures through the end of the tubular prosthesis (Fig 1). The direction of the stitches enables the proximal end of the tube to evert so that the valve prosthesis is placed directly on the annulus (Fig 2). Thus, the position of the valve prosthesis allows direct implantation of the coronary ostia into the conduit (Fig 3).
The graft is fenestrated using an electrical cautery and the coronary artery buttons are reimplanted into the graft with continuous 5-0 polypropylene sutures.
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Fig 1. The valve prosthesis is placed inside the vascular tube and attached with a continuous suture (dotted line A). The conduit is anastomosed to the aortic annulus by a supraannular technique. The dotted line B shows the outer diameter of the aortic annulus.
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Fig 2. The composite graft is anastomosed to the aortic annulus by the supraannular technique. The proximal short margin of the vascular tube is everted.
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Fig 3. Postoperative aortography after aortic root replacement using modified self-assembled valved composite graft with ATS AP (ATS Medical Inc) valve prosthesis. The coronary ostia are attached directly to the conduit.
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This is followed by sewing the distal anastomosis to the aorta. An open distal anastomosis using the transverse aortic arch was performed on 2 patients. In another 2 patients complete aortic arch replacement under circulatory arrest was performed.
One patient underwent additional proximal aorta descending replacement by an elephant trunk technique because of an acute type A aortic dissection with the primary tear situated 5 cm below the left subclavian artery. Bypass grafting was performed in 2 patients to address coronary heart disease. Operative data are presented in Table 2.
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Results
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There were no intraoperative complications or reoperations for bleeding. In 3 patients a pacemaker was implanted in the early postoperative period because of bradycardia. Echocardiographic evaluation before discharge from the hospital showed very good hemodynamics with a mean transvalvular gradient of 10.7 mm Hg (standard deviation ± 2.8 mm Hg) and without any perivalvular leakage or turbulent blood flow. Hemodynamic data are shown in Table 3.
During the follow-up period of up to 14 months all patients were alive and well and no valve-related complications were noted.
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Comment
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Among the total number of patients with aortic valve replacements, the patients with a narrow aortic annulus can account for up to one third [2–4]. In this population valve replacement with a mechanical or stented biological prosthesis can result in residual obstruction of the left ventricular outflow tract.
When considering biological devices this problem can be solved by using homografts or stentless valves for valve replacement, as well as for replacement of the complete aortic root [5–7]. For the implantation of mechanical devices, a solution consists of the use of valve prostheses with improved hemodynamic performance [8–10] and, if this is not sufficient, aortic annulus enlargement offers an effective solution. However, aortic annulus enlargement can increase the operative risk and mortality [3].
Surgical enlargement of the annulus is the only way to allow for a sufficiently large commercially available standard mechanical composite graft to be implanted because the valve is placed at the end of the conduit and its sewing ring has to be anastomosed directly to the annulus. However, in cases of complete aortic root replacement this method is very seldom performed, probably because of the prolonged cross-clamp time and the fear of operative bleeding. Conversely, young, active patients can profit from sufficiently large valve prostheses even if the effect of moderate patient-valve mismatch after aortic valve replacement for late outcome is still subject to discussion [11–13].
Moving the valve prosthesis away from the end into the inside of the tube is a simple procedure that does not increase operative time significantly and allows the implantation of a larger valved conduit with associated hemodynamic benefits. Anastomosing the flexible rim of a tubular prosthesis to the aortic annulus usually permits the use of a valve prosthesis 2 mm in diameter larger than the standard valved conduit in which the rigid sewing ring is directly attached to the annulus. In contrast to available conduits equipped with standard valve prostheses, we used valve prostheses with larger geometric orifice areas and improved hemodynamic performance. In regard to the effective orifice area, this corresponds to a valve that is two sizes larger.
Cabrol and colleagues [14] previously described a comparable surgical approach. The relevant difference is that Cabrol moved the valve prosthesis 2 cm away from the annulus, and therefore an additional graft was necessary to implant the coronary ostia. [14] However, the button technique is currently the preferred surgical procedure [15–17].
Concerning the mean cross-clamp time, the complete procedure in our patient population is comparable with aortic root replacement using standard valved conduits [15–17]. Also, the direct anastomosis between the collagen-coated vascular tube and aortic annulus offers improved hemostasis without the need of any additional preparatory steps.
Replacement of the aortic valve and ascending aorta using the valve composite graft as described offers excellent hemodynamic performance and is a simple and effective method to avoid valve-patient mismatch in patients with a small aortic annulus who need aortic root replacement.
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Acknowledgments
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I would like to thank Silvia Martin and Astrid Kirchner for preparing the article and Monica Meyer for reviewing the article.
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References
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Abstract
Introduction
