Ann Thorac Surg 2003;76:2099-2101
© 2003 The Society of Thoracic Surgeons
Case report
A modified valve-on-valve approach for aortic root replacement
Kazuhiro Kurisu, MD*a,
Yoshie Ochiai, MDa,
Takashi Kajiwara, MDa,
Hiroshi Kumeda, MDa,
Ryuji Tominaga, MDa
a Department of Cardiovascular Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
Accepted for publication April 23, 2003.
* Address reprint requests to Dr Kurisu, Department of Cardiovascular Surgery, Kitakyushu Municipal Medical Center, 2-1-1 Bashaku, Kokurakita-ku, Kitakyushu 802-0077, Japan
e-mail: sytkurisu{at}hkg.odn.ne.jp
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Abstract
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We describe an alternative surgical technique for aortic root replacement in a patient whose aortic valve was previously replaced with a bioprosthesis. It consists of resecting the leaflets of the original bioprosthesis in situ, amputating the struts, and suturing the skirt of a composite graft on the preserved annulus of the original bioprosthesis. Coronary circulation is reconstructed according to the Cabrol modification. This approach simplifies and shortens the procedure of aortic root replacement, minimizing the potential hazard of hemorrhage from the proximal suture line in these cases.
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Introduction
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One of the key points for surgical success of an aortic root replacement is hemostasis at the proximal suture line [1]. Although various techniques have been described for the anastomosis of aortic root [1–3], the risk of bleeding still persists under the present circumstances. Aortic root replacement seems to be a serious surgical challenge [2], especially in cases subsequent to aortic valve replacement. The conventional approach, consisting of digging out the entire prosthesis and reconstructing the aortic root with a composite graft, possesses a larger potential risk of bleeding [2]. Moreover these procedures are very troublesome and time-consuming. In this report, we present a modified valve-on-valve technique [4, 5] in which the annulus of the original bioprosthesis is left intact and the skirt of the composite graft is sutured on this annulus.
A 76-year-old woman was referred to our hospital because of an abnormal cardiac shadow on a chest roentgenogram in an annual follow-up. She had a history of aortic valve replacement using a 23-mm Hancock II bioprosthesis (Medtronic Inc, Minneapolis, MN) for aortic regurgitation 10 years prior, when the aortic root was slightly dilated measuring 35 mm in maximal diameter. Contrast-enhanced computed tomography revealed a large aneurysm of the ascending aorta with a maximum diameter of 66 mm. Consecutive aortography demonstrated that the aneurysm extended from the aortic root to the level of origin of the innominate artery. Echocardiography showed preserved left ventricular function and no prosthetic valvular dysfunction. As a consequence of these situations, we planned an aortic root replacement using a composite graft and hemi-arch replacement.
The surgery was carried out through a repeated median sternotomy. Cardiopulmonary bypass was initiated with the ascending aortic and bilateral axillary arterial perfusion and bi-caval drainages. Intermittent antegrade and retrograde infusion of cold crystalloid cardioplegia was used for myocardial protection. After aortic clamping, the aneurysmal aortic wall was removed and two coronary ostia were prepared as buttons of the aortic wall (Fig 1A).
A composite graft with skirt using a 23-mm Mosaic valve (Medtronic Inc, Minneapolis, MN) and a 30-mm Hemashield graft (Meadox Medicals, Inc, Oakland, NJ) was created intraoperatively. The size of the tubular graft was selected to fit the sewing ring diameter of the 23-mm bioprosthesis (Medtronic Inc). The skirt was tailored to 10 mm in length.
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Fig 1. Operative technique. (A) The aneurysmal aortic wall is removed and two coronary ostia are prepared as buttons of the aortic wall. (B) The leaflets are resected and the struts are amputated. The 2-0 polyester mattress sutures are sequentially passed through the annulus of the original bioprosthesis and skirt of the composite graft. (C) After the completion of the proximal suture line, the coronary circulation is reconstructed according to a Cabrol modification.
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We confirmed an absence of any paravalvular leakage through an inspection of the bioprosthesis. Three leaflets of Hancock bioprosthesis (Medtronic Inc) were resected with a knife blade. The struts were amputated with a wire cutter and scissors to obtain a flat outflow aspect of the bioprosthesis. The 2-0 polyester mattress sutures without pledgets were sequentially passed through the annulus of the prosthesis and skirt of the composite graft in a fashion from inside to outside (Fig 1B). The composite graft was seated on the annulus of the original bioprosthesis, and the sutures were tied down securely. As the position of the neo-annulus was turned to be higher than the original one, direct implantation of coronary ostia to the graft seemed to be somewhat difficult. Therefore, the left and right coronary arteries were reconstructed according to a Cabrol procedure [6] using an 8-mm short Hemashield graft (Meadox Medicals) (Fig 1C). After the completion of the aortic root reconstruction, the heart was reperfused from a branch of the composite graft. There was no bleeding site around the aortic root. Hemi-arch replacement, including an innominate artery reconstruction, was followed under selective antegrade cerebral perfusion and deep hypothermia. Finally, the ascending aortic graft to the hemi-arch graft anastomosis completed the operation.
Postoperative aortography showed aortic neo-annulus on the superior position without any aortic regurgitation (Fig 2).
Coronary angiography revealed a satisfactory coronary flow. On echocardiography, continuous Doppler imaging yielded a peak pressure gradient across the aortic root calculated at 10.3 mm Hg (Fig 3).
The patient was discharged from our hospital and is doing well at 12 months of follow-up on a regimen of oral antiplatelet drug.
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Fig 2. Postoperative aortography shows the aortic neo-annulus being reconstructed in the superior position rather than in the original position. Note the metallic stent of the previously implanted bioprosthesis drawing the original level of aortic annulus.
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Fig 3. Postoperative echocardiography shows the maximal velocity of 1.6 m/s across the aortic root by the continuous Doppler method; then the peak pressure gradient was calculated at 10.3 mm Hg. (AO = aorta; LA = left atrium; LV = left ventricle.).
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Comment
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Bleeding from the proximal suture line is one of the serious complications of aortic root replacement [1], because it is frequently missed before the establishment of systemic circulation. This problem may be more commonly seen in patients after aortic valve replacement [2]. We adopted a new approach based on the valve-on-valve technique [4, 5], which minimizes the potential hazard of bleeding from the proximal suture line. Certainly, we did not experience any bleeding from this dangerous zone. It must be an obvious merit of this modified approach that the surgeon has little anxiety of hemorrhage from the aortic root during this complex procedure. Moreover, this approach simplifies the operation and seems to be more effective in saving time.
This experience leads us to propose this modification as an alternative for aortic root replacement. Fortunately, no significant stenosis or turbulence across the reconstructed aortic root was revealed by postoperative Doppler echocardiography in this particular case. Nevertheless, a few anxieties remain yet to be settled for this approach. Special care must be taken to prevent thromboembolic complications, because configuring the reconstructed aortic root is complex with this technique. As for the reconstruction of coronary circulation, direct coronary reimplantation using a button technique could be another option rather than the Cabrol technique [6]. Moreover, anticoagulation therapy starting with heparin and following up with warfarin and antiplatelet drugs for at least 3 months postoperatively may have to be maintained.
Actually most surgeons dig out the original prosthesis and reconstruct the aortic root with relatively low risk in these cases at the present time; therefore accumulation of experience is mandatory to assess the precise value of this technique hereafter.
In conclusion, our modified technique simplifies the aortic root replacement with reducing the potential risk of bleeding from the proximal suture line. Even though this indication may be limited to include only selected high-risk patients, the initial results encourage us to propose this approach as an alternative choice for aortic root replacement after aortic valve replacement with a bioprosthesis.
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References
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- Michielon G., Salvador L., Col U.D., Valfrè C. Modified button-Bentall operation for aortic root replacement: the miniskirt technique. Ann Thorac Surg 2001;72:S1059-1064.[Abstract/Free Full Text]
- Schepens M.A., Dossche K.M., Morshuis W.J. Reoperations on the ascending aorta and aortic root: pitfalls and results in 134 patients. Ann Thorac Surg 1999;68:1676-1680.[Abstract/Free Full Text]
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- Stassano P., Musumeci A., Losi M.A., Gagliardi C., Spampinato N. Mid-term results of the valve-on-valve technique for bioprosthetic failure. Eur J Cardiothorac Surg 2000;18:453-457.[Abstract/Free Full Text]
- Geha A.S., Massad M.G., Snow N.J. Replacement of degenerated mitral and aortic bioprostheses without explantation. Ann Thorac Surg 2001;72:1509-1514.[Abstract/Free Full Text]
- Cabrol C., Pavie A., Gandjbakhch I., et al. Complete replacement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach. J Thorac Cardiovasc Surg 1981;81:309-315.[Abstract]
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Abstract
Introduction
