Ann Thorac Surg 2007;83:1908-1910
© 2007 The Society of Thoracic Surgeons
How To Do It
New Technique of Aortic Root Reconstruction With Aortic Valve Annuloplasty in Ascending Aortic Aneurysm
Akhtar Rama, MDa,*,
Sylvain Rubin, MDb,
Nicolas Bonnet, MDa,
Iradj Gandjbakhch, PhDa
a AP-HP, Hôpital de la Pitié Salpêtrière, Service de Chirurgie Cardio-Vasculaire, Université Paris VI, Paris, France
b CHU Reims, Hôpital Robert Debré, Service de Chirurgie Cardio-Vasculaire, Université de Reims, Reims, France
Accepted for publication May 22, 2006.
* Address correspondence to Dr Rama, AP-HP, Hôpital de la Pitié Salpêtrière, Service de Chirurgie Cardio-Vasculaire, Université Paris VI, Paris, 75634 France (Email: akhtar.rama{at}psl.aphp.fr).
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Abstract
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We describe a new technique of aortic valve conservation for ascending aortic aneurysm with aortic valvular insufficiency. This technique allows a total anatomic aortic root reconstruction associated with an aortic annuloplasty preventing late annulus dilation and reoperation. Preliminary results demonstrate the feasibility and the safety of this new original procedure.
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Introduction
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Aortic valve preservation during ascending aorta replacements was introduced by Yacoub and colleagues [1] and David and Feindel [2] many years ago. However, some problems persist (ie, the impossibility to prevent the annulus dilation after the Yacoub’s procedure [3] or to preserve the valve mobility as in the David’s procedure [4]. Confronted with these obstacles, we have imagined a new surgical technique that associates the positive effects of remodeling and inclusion techniques.
This conservative surgery recreates the aortic root anatomy, which reduces the stress forces applied on the valve. It also allows a better valve durability without aortic annulus dilation.
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Technique
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Before surgery, a transesophageal echocardiography allows evaluation of the aortic valve, the ascending aorta, and Valsalva’s sinuses (VS). The proximal ascending aorta and coronary ostia liberation are classically achieved. The aortic opening allows one to visualize the annulus and the valve aspect. In front of important lesions, such as retractions or calcifications, the aortic valve must be replaced using aortic valve prosthesis. However, a bicuspid aortic valve is not systematically an indication for valve replacement. Our technique can be used in this case with good preliminary results.
Valsalva’s sinuses are resected a few millimeters above the aortic annulus, and the coronary ostia are individualized (Fig 1A). A 5-0 Prolene suture (Ethicon, Somerville, NJ) is placed on top of the commissures. Six Ticron (Tyco, Norwalk, CT) 2-0 U-shaped sutures are disposed under the aortic annulus, at the same level; three below the valve commissures and three between them, without modifying the aortic valve geometry (Fig 1B).
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Fig 1. (A) Aortic root preparation with resected Valsalva’s sinus. (B) Sub-annular Ticron 2-0 U-shaped sutures. (C) Aortic valve inclusion in a Dacron tube.
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Then sutures are brought through a Dacron (Vascutek, Terumo, Renfrewshire, Scotland) tube graft (from the interior to the exterior). Then these sutures are tied on a Dacron tube as it allows annulus inclusion and reduction (Fig 1C). Sub-annular sutures allow a solid prosthesis fixation on the aortic valve annulus preventing a secondary dilation.
The Dacron prosthesis is incised in an inverted "T" form in front of each commissure (Fig 2A) allowing the commissures to exit out of the prosthesis. Each commissural aortic patch is sutured to the prosthesis (Fig 2B) by an external running 5-0 Prolene suture. Then, the Prolene running suture is interiorized (Fig 2C) and prolonged to the adjacent commissure to realize the circumferential hemostasis (Fig 3A). These three aortic commissural patches increase the Dacron graft diameter and create a new VS and a sinotubular junction is created by one "X" Prolene suture at the top of each commissural aortic patch (Fig 3B). Finally, the two coronary ostia are reimplanted on the aortic prosthesis (Fig 4). The association of the aortic annulus reduction, the VS and the sinotubular junction creations allow a real anatomical reconstruction (Fig 3B).
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Fig 2. (A) Prosthesis incision in front of the aortic commissure. (B) Suture of the "commissural aortic enlargement patch." (C) Final aspect with neo-sinus formation.
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Fig 3. (A) Aortic root reconstruction aspect with running sutures between each commissure. (B) General postoperative findings after coronary reimplantation and distal anastomosis.
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In our preliminary experience, the postoperative echocardiography found a 21 to 23 mm aortic annulus, a 33 to 35-mm VS and a 28-mm sinotubular junction. The presence of sinuses and aortic root expansion allow normal valve mobility. We used this technique for 9 patients presenting grade II–IV aortic valve insufficiency with an ascending aortic aneurysm. All patients presented an aortic annulus dilation and one had a bicuspid aortic valve. The hospital mortality was null and all patients have good valvular results with no or grade I postoperative aortic insufficiency.
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Comment
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Aortic root remodeling and inclusion procedures introduced by Yacoub and colleagues [1] and David and Feindel [2] allow the aortic valve conservation for selected patients presenting ascending aneurysm with early good results [5]. For young patients, the absence of mechanical valve implantation is interesting because of the anticoagulation-related mortality of about 0.4% per year and the prosthesis-related morbidity [6].
Despite these advantages, the late results of remodeling or inclusion techniques reveal some aortic valve failures [3, 5]. The Yacoub’s procedure does not allow durable aortic annulus stabilization [3]. Many reoperated patients present an aortic annulus dilation with a new valvular insufficiency. Bicuspid aortic valves are most often interested by postoperative annulus and leaflet failures [7]. Despite these results, the sinuses creation preserves the valvular mobility without induced leaflet lesions. On the other hand, the David’s procedure stabilizes and reduces the aortic annulus dilation but can induce aortic valve lesions with the need to reoperate despite the introduction of secondary technical modifications [8]. Therefore no real VS is created with a negative impact on the aortic valve mobility. In our technique, we have kept in mind these important points to imagine an anatomical reconstruction of the aortic root. The association of an aortic annulus reduction, VS and sinotubular junction creations probably explain these interesting preliminary results. We highly believe that these results will be confirmed during the follow-up.
In conclusion, this new technique associates all positive points of previous aortic root reconstruction techniques without needing specific prosthesis. The VS and sinotubular junction creations associated with the aortic annulus reduction should increase the aortic valve durability.
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References
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- Yacoub MH, Fagan A, Stassano, Radley-Smith R. Results of valve conserving operations for aortic regurgitation Circulation 1983;68:III1-III510.
- David TE, Feindel M. 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]
- Luciani GB, Casali G, Tomezzoli A, Mazzucco A. Recurrence of aortic insufficiency after aortic root remodeling with valve preservation Ann Thorac Surg 1999;67:1849-1856.[Abstract/Free Full Text]
- Leyh RG, Schmidtke C, Sievers HH, Yacoub MH. Opening and closing characteristics of the aortic valve after different types of valve-preserving surgery Circulation 1999;100:2153-2160.[Abstract/Free Full Text]
- Graeter TP, Aicher D, Langer F, Wendler O, Schafers HJ. Mid-term results of aortic valve preservation: remodeling vs reimplantation Thorac Cardiovasc Surg 2002;50:21-24.[Medline]
- Holper K, Wottke M, Lewe T, et al. Bioprosthetic and mechanical valves in the elderly: benefits and risks Ann Thorac Surg 1995;60(Suppl 2):S443-S446.[Medline]
- Alsoufi B, Borger MA, Armstrong S, Maganti M, David TE. Results of valve preservation and repair for bicuspid aortic valve insufficiency J Heart Valve Dis 2005;14:752-759.[Medline]
- Bethea BT, Fitton TP, Alejo DE, et al. Results of aortic valve-sparing operations: experience with remodeling and reimplantation procedures in 65 patients Ann Thorac Surg 2004;78:767-772.[Abstract/Free Full Text]
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Abstract
Introduction
