Ann Thorac Surg 2007;83:2241-2243
© 2007 The Society of Thoracic Surgeons
How To Do It
Valve-Sparing Reconstruction Within the Native Aortic Root: Integrating the Yacoub and the David Methods
Andras Kollar, MD, PhD*
Department of Surgery, Division of Cardiothoracic Surgery, The University of Texas Medical Branch, Galveston, Texas
Accepted for publication July 31, 2006.
* Address correspondence to Dr Kollar, Department of Surgery, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555. (Email: ankollar{at}utmb.edu).
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Abstract
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I propose an integrated valve-sparing aortic root reconstruction that combines the surgical principles of both the Yacoub and David methods. Valve re-suspension is first completed within the native aortic root; then the graft is anchored to the pledget-reinforced, scalloped true aortic annulus.
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Introduction
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In aortic root aneurysm surgery there are two distinct states of the art valve sparing reconstruction methods. The so called remodeling technique first described by Yacoub and colleagues [1] appropriately restores three dimensional anatomy but it is essentially a supra-annular procedure and is not applicable for an enlarged annulus. In the reimplantation method originating from David and Feindel [2], the prosthesis is secured to the sub-annular level with resuspension of the valve within the graft. This latter procedure is technically more challenging but appropriately addresses aortic annular dilatation. However, the major shortcoming is the loss of natural Valsalva sinuses resulting in increased stress on valve leaflets [3]. To overcome this problem there have been numerous modifications described in the past 15 years (some of them by Dr David himself) and nowadays even new aortic grafts with sinuses are being manufactured. According to a recent review article on the subject most surgeons prefer the David procedure since it prevents annulus re-expansion in the long run [4].
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Technique
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I propose a different technique that integrates the surgical principles of both the Yacoub and David methods combining them into one operation.
For the purpose of the following description I arbitrarily divide the annulus into horizontal and vertical segments. The distinct horizontal segments have strong fibrous support, whereas the vertical segments forming the subcommissural triangles are less defined and are more affected by the forces dilating the aortic root.
- 1 The aortic root is transsected just above the sinotubular junction and the valve leaflets are inspected for symmetry and pathologic abnormalities. The size of the aortic annulus is measured with a Hegar dilator.
- 2 At this point all three Valsalva sinuses are left intact without cutting out the coronary buttons and only limited external dissection is done.
- 3 Subcommissural horizontal mattress sutures with pledgets outside the aortic wall (Fig 1) are used to narrow down the subcomissural triangles and to increase leaflet coaptation. This is a modified valve re-suspension technique, which was originally designed to prevent regurgitation in the pulmonary autograft [5]. For a significantly dilated annulus, typically two sets of sutures are used (Fig 2), but the second (lower level) sutures are not tied at this time, but they are temporarily tightened with red rubber tourniquets. The aim is to narrow down the internal diameter of the root to 21 mm to 23 mm in average size adults, which is again measured with the Hegar dilator.
- 4 Three additional temporary sutures are placed at 120 degrees apart on the free edge of the ascending aorta plicating the sinotubular junction with another set of red rubber tourniquets (Fig 3), and the competence of the aortic valve is tested with the old fashioned "water probe."
- 5 The plicated sinotubular junction is measured with an aortic valve sizer and the depth of each Valsalva sinus (from the sinutubular junction to the base of the cusp) is also measured.
- 6 The tourniquets are released and the coronary ostia are harvested with the usual large buttons leaving approximately 5 mm to 7 mm of the aortic wall above the annulus (again no external subannular dissection is necessary).
- 7 The next step is to place sutures into the "horizontal" segments of the aortic annulus (Fig 4). The valve leaflets are gently held apart and pledgeted 2-0 Tevdek sutures (Genzyme, Fall River, MA) with the pledgets underneath (inside) the annulus are inserted. These "David" sutures pass through the true aortic annulus (ie, similar to aortic valve replacement sutures).
- 8 The graft is selected and prepared per the Yacoub method (based on step 5 measurements). The Tevdek sutures (Genzyme) are placed into the corresponding parts of the tailored "tongues" and the graft is lowered onto the annulus, and then before tying the sutures, they are also passed through the aortic wall remnant to improve hemostasis.
- 9 The vertical-commissural segments are sutured to the graft with running Prolene sutures (Ethicon, Somerville, NJ) incorporating the outside pledgets. After repeat water probe the coronary buttons are reattached followed by the distal aortic suture line.
- 10 The "re-suspended" aortic annulus has a 3-dimensional pledget support that follows the natural scallops of the true annulus (Fig 5). The horizontal segments are supported with "inside" pledgets, the vertical segments are strengthened with "outside" pledgets, and the graft is anchored to this reinforced annulus.
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Fig 1. External subcommissural annuloplasty—the sutures "re-suspend" the vertical part of the aortic valve leaflets within the native aortic root in between a sandwich layer of aortic wall and pledgets. These sutures are designed to prevent subcommissural dilatation.
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Fig 2. External subcommissural annuloplasty—the dilated aortic root is significantly narrowed by reducing all three subcommissural triangles.
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Fig 4. Subcommissural pledgeted "David" sutures—these sutures also anchor the graft to the strongest part of the true aortic annulus.
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Fig 5. The completed proximal suture line follows the scalloped true aortic annulus while the original sinus Valsalva architecture is restored (Yacoub principle).
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Comment
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So far, the procedure has been performed in 3 patients, all having symmetrically enlarged root aneurysms (6–7 cm). The first patient presented with type A aortic dissection and a root aneurysm, and the aortic pathology was accidentally discovered in the other 2 patients. Intraoperative transesophageal echocardiography after repair showed mild aortic insufficiency in the first case and trace aortic insufficiency in the subsequent cases. One patient required re-exploration for hemostasis, but the bleeding was not from the aortic suture lines.
In comparison with the supra-annular Yacoub remodeling and the infra-annular David re-suspension methods the described operation is a true annular reconstruction that restores a 3-dimensional (scalloped) aortic annulus anatomy. Periaortic dissection and suturing inside the graft are avoided, both being critical steps for the success of the David procedure. As opposed to the Yacoub method, it addresses annular enlargement and the graft is anchored to the reinforced true annulus. Other important aspects of the proposed new technique are the early testing with the water probe and the exact measurements for graft sizing and tailoring, rendering sinus Valsalva restoration relatively easy. I believe this reconstruction perfectly restores aortic root anatomy (Fig 6).
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Fig 6. Follow up 2-dimensional echocardiography 7 months after the operation—parasternal long axis view. Note the restored root anatomy with distinct neosinuses.
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Acknowledgments
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I would like to pay my respect to Dr Francis Robicsek. Through his demanding training combined with personal example and inspiration he has directly contributed to the success of this operation.
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References
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- Yacoub MH, Fagan A, Stassano P, Radley-Smith R. Results of valve conserving operations for aortic regurgitation (abstract) Circulation 1983;68:311-312.
- 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;103:617-621.[Abstract]
- Beck A, Thubrikar MJ, Robicsek F. Stress analysis of the aortic valve with and without the sinuses of valsalva J Heart Valve Dis 2001;10:1-11.[Medline]
- Albes JM, Stock UA, Hartrumpf M. Restitution of the aortic valve: what is new, what is proven, and what is obsolete? Ann Thorac Surg 2005;80:1540-1549.[Abstract/Free Full Text]
- Kollar A, Hartyanszky I. External subcommissural annuloplasty to prevent regurgitation in the pulmonary autograft Interactive Cardiovascular and Thoracic Surg 2003;2:183-185.
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A. C. Kollar, S. D. Lick, and V. R. Conti
Valve-Sparing Aortic Root Reconstruction Using In Situ Three-Dimensional Measurements.
Ann. Thorac. Surg.,
June 1, 2009;
87(6):
1795 - 1800.
[Abstract]
[Full Text]
[PDF]
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Abstract
Introduction
