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Ann Thorac Surg 2005;80:839-843
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Valve-Sparing Aortic Root Repair With Patch Technique

Paul P. Urbanski, MD *

Department of Cardiovascular Surgery, Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany

Accepted for publication December 28, 2004.

* Address reprint requests to Dr Urbanski, Herz- und Gefaess-Klinik, Salzburger Leite 1, 97616 Bad Neustadt, Germany (Email: p.urbanski{at}herzchirurgie.de).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Addendum
 The Thoracic Surgery Foundation...
 References
 
BACKGROUND: In the valve-sparing aortic root repair technique presented, each pathologic sinus is replaced with a teardrop-shaped patch. In this study, the clinical and echocardiographic results after the first 20 procedures are evaluated.

METHODS: Between September 2000 and May 2004, 20 patients underwent aortic root repair using a patch technique. Eight patients had an acute type A aortic dissection and 12 patients had an aneurysm of the ascending aorta. In 12 cases, the aortic root was reconstructed with three patches, in 1 case with two patches, and in 7 cases with one patch.

RESULTS: The postoperative echocardiography at discharge showed no aortic regurgitation in 15 cases and trivial regurgitation in 5 cases. Three patients with aortic dissection as an initial pathologic diagnosis died during a median follow-up period of 14.5 months (range, 0.5 to 32 months). At the time of follow-up, the echocardiographic findings in all 17 survivors remained unchanged from the early postoperative examinations. Median peak and mean transvalvular gradients were 8 mm Hg (range, 3.2 to 14 mm Hg) and 4 mm Hg (range, 1.7 to 6 mm Hg), respectively.

CONCLUSIONS: The technique presented allows an individualized reconstruction of the sinuses of Valsalva, a simplified sizing of the vascular graft, and the creation of a new sinotubular junction resulting in good hemodynamic conditions. The technique is especially advantageous in patients in whom replacement of all sinuses is not necessary.


   Introduction
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 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Addendum
 The Thoracic Surgery Foundation...
 References
 
Complete replacement of the ascending aorta using a valved composite graft has proven to be an effective, safe, and durable method for treating complex diseases of the aortic valve and ascending aorta [1, 2]. Nevertheless, in selected patients with aortic insufficiency combined with an ascending aortic aneurysm, a valve-sparing aortic root replacement can be performed with superior hemodynamic results. Two surgical methods can be used for these cases: aortic root replacement with valve reimplantation or valve remodeling [3, 4]. In modification of the latter method, introduced by the author in 2000, the pathologic sinuses of Valsalva are replaced with individual polyethylene terephthalate fiber (Dacron) patches (InterGard; InterVascular, La Ciotat, France), and the sinotubular junction is newly created [5]. The aim of this study was to evaluate the clinical and echocardiographic results after the first 20 procedures.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Addendum
 The Thoracic Surgery Foundation...
 References
 
Patients
Between September 2000 and May 2004, 20 patients underwent aortic root repair using a patch technique. The group included 12 men and 8 women with a median age of 63 years (range, 34 to 77 years). Eight patients had an acute aortic dissection and 12 patients had a chronic aortic aneurysm: 1 false and 11 true aneurysms. Preoperative patient characteristics are shown in Table 1. Table 2 demonstrates that the severity of aortic insufficiency did not depend on the aortic pathologic disease.


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  		Table 1. Preoperative Patient Characteristics
 

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  		Table 2. Relationship Between Aortic Disease Pathology and Aortic Valve Insufficiency
 
Surgical Technique
Median sternotomy and extracorporal circulation were used in all patients. Depending on the aortic disease or extent of surgery, the cannulation site for arterial return was the aortic arch (6 patients), the common femoral artery (6 patients), the left common carotid artery (4 patients), and the combination of two arterial accesses, femoral as well as carotid artery (4 patients) [6]. Myocardial protection was instituted with antegrade cold crystalloid cardioplegia. In all patients with acute aortic dissection, the distal repair was performed in circulatory arrest without cross-clamping of the aorta before proximal repair. Five patients with acute aortic dissection underwent complete aortic arch replacement. The ascending aorta was resected up to the commissures of the aortic valve. The distorted sinuses of Valsalva were excised, leaving a 2- to 3-mm rim of aortic wall attached to the aortic valve. In the majority of patients with acute aortic dissection, it was not necessary to excise all three sinuses. Only in 1 patient did all three sinuses have to be replaced because of aortic root dilatation with a diameter of 6 cm. In contrast, in the group with chronic aneurysm, in all but 1 patient, all three sinuses were resected (Table 3). From the coronary sinuses, small buttons of aortic wall around the ostia were separated. For selection of the vascular graft (InterGard; InterVascular, La Ciotat, France) the aortic annulus was measured with the valve sizer, and a tube with the same or 1 mm smaller diameter was chosen; for example, a 24-mm tube for an aortic annulus with a diameter of 24 to 25 mm.


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  		Table 3. Relationship Between Aortic Disease and Number of New Sinuses
 
According to the number of the sinuses that had to be replaced, one to three patches were excised from the tube and trimmed to teardrop shapes compatible with the size of the respective valve cusps (Fig 1A). The size of each patch was judged visually, keeping in mind that the sum of distances between the commissures results in the whole aortic root circumference at the level of sinotubular junction and should be equal to the triple diameter of the vascular tube. In case of symmetric valves (Fig 1), the distances are equal to each other and to the diameter of the tube.



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  		Fig 1. (A) Ascending aorta and sinuses of Valsalva are excised. Three teardrop-shaped patches for sinus replacement are prepared according to the size of the respective valve cusps. (B) The patches are sewn to the rim of the aortic wall close to the aortic valve.

 
The patches were sewn to the rim of the aortic wall with a 5-0 polypropylene running suture beginning at the nadir of the sinuses and continuing toward the commissures. It is important not to cut the patches too small. They can be trimmed to the final form during sewing. At the top of the commissures the sutures were left untied, and the coaptation of the cusps was evaluated (Fig 1B). After fenestration of the new left and right coronary sinuses, the coronary buttons were reimplanted using 5-0 polypropylene running sutures.

To create a new sinotubular junction, the Dacron tube was anastomosed with a 4-0 polypropylene running suture to the reconstructed aortic root at a level above the top of the commissures. On reaching the commissures, this suture was tied to the 5-0 sutures of the new sinuses. Neither fibrin sealants nor adhesive glue were used in any of the patients. To complete the procedure, the Dacron tube was tailored to the appropriate length and anastomosed distally.

Additional coronary artery bypass grafting was performed in 4 patients. In 12 patients, an aortic arch repair was performed. Operative data are shown in Table 4.


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  		Table 4. Operative Data
 
All patients received a transthoracic echocardiogram before discharge. For follow-up, the patients and their physicians were contacted. For all survivors, echocardiographic examinations were performed at our hospital at the time of follow-up.


   Results
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 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Addendum
 The Thoracic Surgery Foundation...
 References
 
One patient died within 30 days after surgery. There was one delayed sternotomy closure in a patient with acute aortic dissection because of coagulopathy. Also because of a coagulopathy, one further patient (repeat redo) had to undergo another thoracotomy. One patient with acute aortic dissection experienced a cerebrovascular incident. Other relevant early complications were pericardial effusions requiring drainage in 2 patients and respiratory failure requiring tracheostomy in 1 patient.

Intraoperative and predischarge echocardiographic examinations were completed for all 20 patients. In 15 patients, the aortic valve was competent, and in 5 patients it showed a trivial insufficiency.

Three patients with aortic dissection as initial pathologic diagnosis died during a median follow-up period of 14.5 months (range, 0.5 to 32 months), but in no case as a result of aortic or valvular cause. One of them died shortly after entering a rehabilitation hospital. This female patient (56 years) had undergone an ascending aortic replacement in 1996 because of acute aortic dissection. During that operation, French glue was used to approximate the dissected layers in the region of the aortic root as well as in the aortic arch. She later developed a large false aneurysm at the distal suture line and was treated successfully with a complete arch replacement in 1999. Four years later, she had an aneurysm at the proximal suture line combined with mild aortic insufficiency. The early postoperative course after aortic root repair with replacement of all three sinuses was uneventful, apart from a repeat thoracotomy for bleeding and atrial fibrillation treated with Sotalol. She died suddenly on the 15th postoperative day. At autopsy, no morphologic pathologic disease was discovered; thus, a rhythm disorder was presumed to be the cause of death. A second patient (female, 45 years) with acute dissection died 6 months after surgery. She had severe cerebrovascular injury perioperatively and subsequently died of pneumonia. A third patient (male, 77 years), also with an acute dissection, had severe dysphagia caused by a giant hiatal hernia and died 5 months after surgery of aspiration pneumonia.

The median follow-up period for survivors was 16 months (range, 4 to 32 months). At the time of follow-up, 16 survivors were in New York Heart Association functional class I and 1 in class II. The echocardiographic findings remained unchanged as compared with the early postoperative examinations. The findings showed no aortic regurgitation in 13 patients and trivial regurgitation in 4 patients. The median peak and mean transvalvular gradients were 8 mm Hg (range, 3.2 to 14 mm Hg) and 4 mm Hg (range, 1.7 to 6 mm Hg), respectively.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Addendum
 The Thoracic Surgery Foundation...
 References
 
Ascending aortic replacement with valve reimplantation or remodeling has recently gained acceptance as a suitable valve-sparing procedure in selected patients with aortic regurgitation combined with aortic ectasia. The first clinical results proved that there is no significant difference in outcome between these two methods. This means that the choice of the method remains a matter of the surgeon’s preference [7–9].

However, in experiments, the opening and closing behavior of the aortic valve preserved with the remodeling procedure appeared to be more physiologic when compared with the reimplantation technique [10]. Leyh and associates [11] also demonstrated echocardiographically nearly normal movements of the preserved aortic valve in patients after the remodeling procedure.

Because of the complicated sizing of the tube required and the difficult surgical technique, the valve-sparing aortic root replacement remains a surgical challenge. This has led to many modifications of the surgical technique as well as the grafts, especially for the reimplantation procedure [12, 13]. This patch technique described is a modification of the remodeling procedure.

In the original method of aortic root replacement with valve remodeling, there was no narrowing of the tube at the level of the sinotubular junction [3]. Dilatation of the vascular prosthesis at this level could be a potential cause of recurrent aortic insufficiency, which was the most common cause of surgical revision [14].

For the remodeling procedure, Zehr and colleagues [15] have proposed their own prosthesis, with three symmetrical new sinuses and a sinotubular junction. Because this prosthesis has a predetermined form, the valve anatomy of the patient must be adjusted to the graft. If the patient has asymmetric cusps, which is relatively often the case [16], the discrepancy between the cusps and the symmetric new sinuses creates a technical problem. The same problem can also occur when using a valveless allograft for the remodeling procedure [17] when there is a mismatch between the size of the patient’s cusps and the sinuses of the allograft. Both above-mentioned grafts are, therefore, only suitable for a patient with three symmetric valve cusps.

The patch technique described offers the possibility of a case-based, individualized reconstruction of the sinuses of Valsalva. The suture line between the patch and the aortic rim is easier and quicker to accomplish than the suture line with a tongue-shaped vascular tube. The time saved makes up for the time for the additional suture line between the reconstructed aortic root and the ascending aortic prosthesis. This suture line creates a new sinotubular junction, which may be crucial for the favorable function of the preserved valve. The diameter of the new sinotubular junction is determined by the size of the tube selected. Our experience to date shows that the size of the tube can be measured at the native aortic annulus of the patient. Figure 2 demonstrates the preoperative and postoperative aortogram of a patient with "annuloaortic ectasia" and an annulus diameter of 27 mm, in whom an aortic root replacement with three patches and a tube with a 26-mm diameter was performed.



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  		Fig 2. (A) Preoperative aortogram of the patient with "annuloaortic ectasia" and moderate aortic insufficiency. (B) Postoperative aortogram of the same patient after ascending aortic replacement with a tube and aortic root repair with three single patches.

 
In addition, the technique offers the advantage of replacing only the distorted sinuses and allowing the nearly normal sinuses to remain untouched. Especially in the case of acute aortic dissection without aortic root dilatation, only the dissected sinuses are replaced. In our patient group with acute aortic dissection, only 1 patient needed replacement of all three sinuses.

Westaby and associates [18] have demonstrated that in atheromatous aneurysm it is also not necessary to always replace all sinuses. In our patient group there were 3 patients with atheromatous aneurysms, in 2 of whom all sinuses had to be replaced, whereas in 1 patient an excellent result was achieved by replacing only one sinus.

In conclusion, the technique presented leads to case-based, individualized reconstruction of the sinuses of Valsalva with simplified sizing of the vascular graft and creation of a new sinotubular junction, resulting in a favorable clinical and hemodynamic outcome. This technique is especially advantageous in patients with asymmetric anatomy of the aortic root or patients in whom replacement of all sinuses is not necessary.


   Addendum
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 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Addendum
The Thoracic Surgery Foundation...
 References
 
Until December 2004, I performed the technique described in 35 patients at our institution. We continue to follow all patients after aortic root repair using this technique and plan to provide late results as they become available.


   The Thoracic Surgery Foundation for Research and Education
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 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Addendum
 The Thoracic Surgery Foundation...
References
 
Grants, Fellowships, and Career Development Awards
The Thoracic Surgery Foundation for Research and Education (TSFRE) was founded to bring together the research and education support efforts of the four major societies in cardiothoracic surgery in the United States: the American Association for Thoracic Surgery (AATS), The Society of Thoracic Surgeons (STS), the Southern Thoracic Surgical Association (STSA), and the Western Thoracic Surgical Association (WTSA). Because of its close and continuing relationship with organized cardiothoracic surgery, TSFRE attracts the highest quality research award applicants and truly outstanding reviewers.

Any surgeon who meets the eligibility requirements is invited to submit an application. Research grants will be judged separately from research fellowship applications. In general, top-scoring applications in each category will receive priority with respect to funding.

Multiple fellowship applications under the sponsorship of an individual mentor, or multiple grant applications from a single institution will be accepted and reviewed, as long as there is no significant scientific overlap. Only under extraordinary circumstances will the TSFRE fund simultaneous awards to a single institution.

This year, TSFRE is proud to offer the following awards to the most promising cardiothoracic surgeon-scientists:

The Nina Starr Braunwald Career Development Award
Provides a biennial award of $100,000 for 2 years to support the research career development of a woman cardiac surgeon who holds a full-time faculty appointment and who is within 10 years of completion of thoracic surgery residency. Deadline: November 1

TSFRE Research Grants
Provides operational support of original research efforts by cardiothoracic surgeons who have completed their formal training, and who are seeking initial support and recognition for their research program. Awards of up to $30,000 a year for up to 2 years are made each year to support the work of an early-career cardiothoracic surgeon (within 5 years of first faculty appointment). Deadline: November 1

TSFRE Research Fellowships
Provides support of up to $35,000 a year for up to 2 years for surgical residents who have not yet completed cardiothoracic surgical training. Deadline: November 1

TSFRE Career Development Awards
Provide salary support of up to $50,000 a year for up to 2 years for applicants who have completed their residency training and who wish to pursue investigative careers in cardiothoracic surgery. Deadline: November 1

TSFRE/NHLBI Jointly Sponsored Mentored Clinical Scientist Development Award (TSFRE/NHLBI MCSDA) K08 or K23
Provides support to outstanding clinician research scientists who are committed to a career in cardiothoracic surgery research and have the potential to develop into independent investigators. The award is $150,000 a year ($75,000 from TSFRE and $75,000 from NHLBI) plus $25,000 indirect support from the NHLBI and supports a 3-, 4- or 5-year period of didactic training and supervised research experience. Deadline: May 31

TSFRE/NCI Jointly Sponsored Mentored Clinical Scientist Development Award (TSFRE/NCI MCSDA) K08 or K23
Provides support to outstanding clinically trained professionals who are committed to a career in laboratory or field-based research and have the potential to develop into independent investigators. The award is $150,000 a year ($75,000 from TSFRE and $75,000 from NCI) plus $30,000 indirect support from the NCI and supports a 5-year period of supervised research that integrates didactic studies with laboratory or clinically based research. Deadline: February 1 and October 1

The American Association for Thoracic Surgery Awards
Provides $75,000 in support for 1 year through the Evarts A. Graham Memorial Traveling Fellowship to a non-North American young cardiothoracic surgeon future international leader for further development in the United States. The AATS also provides $75,000 a year for 2 years of support for young North American cardiothoracic surgeons committed to pursuing an academic career in cardiothoracic surgery through the AATS Research Scholarship. Additionally, AATS provides $5,000 travel grants to broaden the educational experience of North American residents in their final year of residency through the Resident Traveling Fellowship. Deadline: July 1

Applications will be available online only and can be found at www.tsfre.org. For more information, please address inquiries to:

Chair, Research Committee

Thoracic Surgery Foundation for Research and Education

900 Cummings Center, Suite 221-U

Beverly, MA 01915

Telephone: (978) 927-8330


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Addendum
 The Thoracic Surgery Foundation...
 References
 

  1. Urbanski PP, Wagner M, Zacher M, Hacker RW. Aortic root replacement versus aortic valve replacementa case-match study. Ann Thorac Surg 2001;72:28-32.[Abstract/Free Full Text]
  2. Hagl C, Strauch JT, Spielvogel D, et al. Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival? Ann Thorac Surg 2003;76:698-703.[Abstract/Free Full Text]
  3. Sarsam MAI, Yacoub M. Remodeling of the aortic valve annulus J Thorac Cardiovasc Surg 1993;105:435-438.[Abstract]
  4. David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta J Thorac Cardiovasc Surg 1992;103:617-622.[Abstract]
  5. Urbanski PP. Valve-preserving aortic root reconstruction [Letter] J Thorac Cardiovasc Surg 2001;121:1220.[Free Full Text]
  6. Urbanski PP. Cannulation of the left common carotid artery for proximal aortic repair J Thorac Cardiovasc Surg 2003;126:887-888.[Free Full Text]
  7. Schäfers H-J, Fries R, Langer F, Nikoloudakis N, Graeter T, Grundmann U. Valve-preserving replacement of the ascending aortaremodeling versus reimplantation. J Thorac Cardiovasc Surg 1998;116:990-996.[Abstract/Free Full Text]
  8. David TE, Ivanov J, Armstrong S, Feindel CM, Webb GD. Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta Ann Thorac Surg 2002;74(Suppl):S1758-S1761.[Abstract/Free Full Text]
  9. Erasmi AW, Stierle U, Bechtel M, Schmidtke C, Sievers HH, Kraatz EG. Up to 7 years’ experience with valve-sparing aortic root remodeling/reimplantation for acute type A dissection Ann Thorac Surg 2003;76:99-104.[Abstract/Free Full Text]
  10. Furukawa K, Ohteki H, Cao Z-L, et al. Evaluation of native valve-sparing aortic root reconstruction with direct imagingreimplantation or remodeling?. Ann Thorac Surg 2004;77:1636-1641.[Abstract/Free Full Text]
  11. Leyh RG, Schmidtke C, Sievers HH, Yacoub MH. Opening and closing characteristic of the aortic valve after different types of valve-preserving surgery Circulation 1999;100:2153-2160.[Abstract/Free Full Text]
  12. Miller DC. Valve-sparing aortic root replacement in patients with the Marfan syndrome J Thorac Cardiovasc Surg 2003;125:773-778.[Free Full Text]
  13. Hopkins RA. Aortic valve leaflet sparing and salvage surgeryevolution of techniques for aortic root reconstruction. Eur J Cardiothoracic Surg 2003;24:886-897.[Abstract/Free Full Text]
  14. Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root J Thorac Cardiovasc Surg 1998;115:1080-1090.[Abstract/Free Full Text]
  15. Zehr KJ, Thubrikar MJ, Gong GG, Headrick JR, Robicsek F. Clinical introduction of a novel prosthesis for valve-preserving aortic root reconstruction for annuloaortic ectasia J Thorac Cardiovasc Surg 2000;120:692-698.[Abstract/Free Full Text]
  16. Morishita K, Murakami G, Koshino T, et al. Aortic root remodeling operationhow do we tailor a tube graft?. Ann Thorac Surg 2002;73:1117-1121.[Abstract/Free Full Text]
  17. Schoof PH, Tjien ATJ, Lam J, et al. Valve-sparing aortic root reconstruction with a valveless aortic allograft J Thorac Cardiovasc Surg 2003;126:282-283.[Free Full Text]
  18. Westaby S, Saito S, Anastasiadis K, Moorjani N, Jin XY. Aortic root remodeling in atheromatous aneurysmsthe role of selected sinus repair. Eur J Cardiovasc Surg 2002;21:459-464.



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