Ann Thorac Surg 2006;82:1137-1139
© 2006 The Society of Thoracic Surgeons
How to do it
Suspension String: A New Method of Aortic Valvuloplasty for Aortic Insufficiency and Ventricular Septal Defect
Zhixiong Huang, MD*
Department of Cardiovascular Surgery, Cardiovascular Institute, Fu Wai Hospital, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
Accepted for publication July 5, 2005.
* Address correspondence to Dr Huang, Department of Cardiovascular Surgery, Cardiovascular Institute, Fu Wai Hospital, A 167 Beilishi Road, Fuchengmenwai, Beijing, 100037 China (Email: zhixiongh{at}sina.com).
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Abstract
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In a 4-year-old boy with ventricular septal defect, severe aortic insufficiency, and mild infundibular stenosis, a new method was used to reconstruct the prolapsed aortic cusp. Two ends of a pledged stitch were passed through the aorta at each side of the right, noncoronary commissure and then through another pledget, and were then tied repeatedly in a row. The length of the row of knots was equal to that of the free edge of left coronary or noncoronary leaflet. The remainder of the stitch was passed through a pledget and then the aortic wall at each side of the left and right coronary commissure to the extraaortic wall pledget and were tied. A suspension string was formed by the row of knots and supported by a Teflon (Dupont Teflon, Wilmington, DE) felt pledget sandwich at each of two commissures. The free margin of the prolapsed cusp was attached to the suspension string by a continuous suture. The concomitant anomalies were corrected. The result was satisfactory.
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Introduction
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In regard to ventricular septal defects (VSDs) with aortic insufficiency, previous techniques for prolapsed aortic cusp reconstruction have achieved some good results [1–4]. If the edge of the prolapsed cusp is retracted and thickened, repair is usually not possible [5]. Herein this presentation describes a new method of creating a suspension string to reconstruct the prolapsed aortic cusp.
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Technique
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A 4-year-old boy had VSD, severe aortic insufficiency and mild infundibular stenosis. His blood pressure was 120/40 mm Hg. He had a to-and-fro murmur in the aortic area. The electrocardiogram revealed left ventricular hypertrophy. The chest roentgenogram showed generalized cardiac enlargement with a cardiothoracic ratio of 0.63. Echocardiography indicated dilatation of the left ventricle with a 50-mm end-diastolic diameter, a subaortic VSD (10 mm in diameter), a mild infundibular stenosis with a gradient of 46 mm Hg. The aortic valve was tri-leafed, the right coronary cusp was significantly prolapsed, and the annulus had dilatation with severe aortic insufficiency.
The operation was done using a midline sternotomy with cardiopulmonary bypass. A proximal aortotomy was made, and cardioplegia solution was administered directly into the coronary orifices. The right coronary cusp was extensively prolapsed through the VSD. The center and a portion of the prolapsed cusp near the right, noncoronary commissure of the free margin was thickened and retracted, whereas the remainder of the free margin, which was adjacent to the left and right coronary commissure, was thinned and discontinuous from the commissure. The right coronary sinus was enlarged. A doubly committed subarterial VSD was 25 mm in diameter. A muscular, stenotic ring 8 mm in diameter was found in the infundibulum.
A new valvuloplasty was used for repairing severe aortic insufficiency. Two ends of a pledgetted stitch of 4-0 polypropylene were passed through the aorta into the lumen at each side of the right, noncoronary commissure and were then passed through another pledget, and knots were repeatedly tied in a row. The length of the row of knots was equal to that of the free edge of left coronary or noncoronary leaflet. A pledget was added. Then the stitches were passed through the aortic wall at each side of the left and right coronary commissure and through an extraaortic pledget, which were then tied (Fig 1). A suspension string was formed by the row of knots and supported by a Teflon (Dupont) felt pledget sandwich at each of two commissures. The free margin of the prolapsed cusp was attached to the suspension string by a continuous suture using 5-0 polypropylene (Fig 2); its thickened and retracted portion was attached directly, and its thinned portion was supported by a strip of autologous pericardium. The muscular stenotic ring in the infundibulum was resected, and the VSD was patched using a continuous suture through a right ventriculotomy. The postoperative blood pressure was 100/60 mm Hg, and the murmur had disappeared. Echocardiography showed that the left ventricle, end-diastolic diameter decreased to 43 mm; only trivial aortic insufficiency was detected, the shunt across the VSD disappeared, and the blood velocity across the pulmonary valve was normal. The patient had an uneventful postoperative course and was discharged from the hospital 7 days after surgery. At the latest follow-up (5 months after discharge) the patient recovered to normal activity; the blood pressure was 90/60 mm Hg, no murmur was detected, the size of his heart was normal on chest roentgenogram, and echocardiography showed that aortic insufficiency was absent.
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Fig 1. Two ends of a pledgetted stitch were passed through the aorta at each side of the right, noncoronary commissure and then through another pledget, and then knots were repeatedly tied in a row. The length of the row of knots was equal to that of the free edge of the left coronary or noncoronary leaflet. The remainder of the stitch ends were passed through a pledget, then the aortic wall at each side of the left and right coronary commissure, and through an extraaortic pledget, and were then tied. A suspension string was a formed by the row of knots, which was supported by a Teflon (Dupont Teflon, Wilmington, DE) felt pledget sandwich at each of two commissures.
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Fig 2. The free margin of the prolapsed cusp was attached to the suspension string by a continuous suture.
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Comment
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Prolapse of one of the aortic cusps may occur with outlet or perimembranous VSDs. Patients with outlet defects usually have deficiency of muscular or fibrous support below the aortic valve cusps with herniation of the right coronary leaflet through the VSD. However, there is still no agreement about the mechanism of cusp prolapse causing aortic insufficiency. The usual explanation is that the valve leaflet lacks support, which causes prolapse and eventually leads to stretching and elongation of the free margin of the cusp, which slips below the support of the other two leaflets and allows blood to spill into the ventricle [3]. Based on the presumption that progressive elongation of the free edge of the prolapsed cusp causes aortic insufficiency, a variety of valvuloplasty techniques have been focused on treating this elongated, free edge of the prolapsed cusp, including shortening [1, 2], plication [3] and excision of the redundant free edge [6]. Each has achieved good results in certain patients, particularly in those with mild aortic insufficiency. In advanced cases, the prolapsed cusp may become thickened and retracted, which aggravates aortic insufficiency and results in ineffective reconstruction of the prolapsed cusp using traditional methods. This may lead to the need for aortic valve replacement [5]. For these patients with moderate or severe aortic insufficiency, it is effective to perform the procedure proposed by Wu, using an autologous pulmonary cusp to replace the prolapsed aortic cusp [7]. This procedure is complex and at the cost of harvesting an autologous pulmonary valve cusp. The technique described in this article, creating a suspending string, is simple and effective with the purpose of reconstructing a near normal line of coaptation. It can achieve almost complete aortic competence in patients with moderate or severe aortic insufficiency as the case previously described. If the free margin of the prolapsed cusp becomes thickened and is seriously retracted, this technique is still useful by completely resecting the seriously thickened and retracted cusp and reconstructing it with a pericardial patch by attaching the free edge of the patch to the suspending string with a continuous suture.
The idea of creating a suspension string for aortic valvuloplasty came to mind during the following procedure. A 5-year-old girl with congenital subvalvar aortic stenosis underwent resection of a subvalvar fibrous ridge through a transaortic approach. When the right aortic cusp was retraced to expose the subvalvar fibrous ridge, the first assistant accidentally tore the free edge from the remainder of the cusp. The remainder of the cusp was attached to the free edge like a suspension string with a continuous suture of 6-0 polypropylene. The patient recovered and on her 1-year postoperative, follow-up echocardiogram the aortic insufficiency was absent.
The long-term result of the current case requires further observation.
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References
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Abstract
Introduction
