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Ann Thorac Surg 2007;83:2248-2250
© 2007 The Society of Thoracic Surgeons

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How To Do It

Modified Simple Sliding Aortoplasty for Supravalvar Aortic Stenosis

Asan Medical Center, Seoul, Korea

Accepted for publication August 29, 2006.

^_* Address correspondence to Dr Seo, Asan Medical Center, 388-1 Pungnap 2 Dong, Songpa-gu, Seoul, 138-736, Korea. (Email: dmeso{at}amc.seoul.kr).

	Abstract

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We describe a modified simple sliding aortoplasty for supravalvar aortic stenosis. This technique is easier, has a more physiologic approach, and has the advantage of not using foreign material to provide aortic growth potential in children. For the patients presented in this study, the mid-term results of modified simple sliding aortoplasty have showed good results.

	Introduction

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The surgical approach for treating supravalvar aortic stenosis has evolved from plain patch technique to 3-dimensional patch repair [1]. However, this 3-dimensional patch repair is a complex, time-consuming procedure.

We propose a modified simple sliding aortoplasty for supravalvar aortic stenosis without using foreign material.

	Technique

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Between June 2001 and December 2005, 7 children (mean age, 7 yrs; range, 3 to 12 yrs) with supravalvar aortic stenosis were surgically treated. Four patients had clinical features of Williams syndrome. Three patients had undergone right pulmonary artery angioplasty due to right pulmonary artery stenosis. One patient had undergone aortic valve commissurotomy due to bicuspid aortic valve.

A standard median sternotomy was used in all patients. Cardiopulmonary bypass was instituted with a cannula for arterial return in the ascending aorta and a venous single cannula in the right atrium. On bypass, meticulous dissection around the arch vessels was performed to lessen the tension on the future suture line.

Cardiac arrest was achieved using cold antegrade cardioplegic solution. The aorta was transected obliquely several millimeters distal to the point of stenosis.

This was to allow resection of the narrowed segment under direct visualization from the luminal side as the proximal resection must be just above the commissure between the left and right coronary cusps. As a result, the resected segment may be around 1 cm in length. An incision was then made into the noncoronary sinus of the proximal aorta, and a counter incision into the lesser curvature of the ascending aorta as shown in Fig 1A was made so as to create the appropriate diameter of the new sinotubular junction. The tethered fibrous tissue was then excised, and the thickened commissural tissue was mobilized. The proximal and distal aorta was then anastomosed directly with 5-0 or 6-0 Prolene running suture (Ethicon, Somerville, NJ) as is routine in arterial switch operation (Fig 1B). Absorbable sutures or an interrupted suture technique may be used in anastomosis.

View larger version (44K): [in this window] [in a new window]   Fig 1. (A) Dashed line depicts the incision into the noncoronary sinus of the proximal aorta and another one into the lesser curvature of the ascending aorta. (B) The proximal and distal aorta is then anastomosed directly with 5-0 or 6-0 Prolene running suture (Ethicon, Somerville, NJ).

	Comment

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Surgical repair of supravalvar aortic stenosis was first accomplished by insertion of a diamond-shaped prosthetic patch across an incision into the noncoronary sinus of Valsalva [2]. Multiple surgical approaches have been described to relieve supravalvar aortic stenosis, including Doty’s patch aortoplasty [3] and Brom’s three-patch technique [4].

Brom’s three-patch technique, the most widely used technique, however, results in the three Valsalva sinuses being made the same size, which is not the natural situation. A further disadvantage of this technique is that it uses foreign material, resulting in a lack of growth potential for the aorta in children.

To compensate these problems, we propose modified simple sliding aortoplasty. This technique is easier to perform, more timesaving, and has the advantage of allowing for aortic growth in children.

As McAlpine [5] reported, under normal physiologic conditions the differences in annular circumferences encompassing the various sinuses can be as great as 20% to 25%; this technique does not aim to create sinuses of the same size, but results in a more physiologic condition.

For the patients presented in this study, the mid-term results of modified simple sliding aortoplasty have proved promising. Long-term follow-up is required to determine if this technique ultimately improves aortic anatomy significantly enough to decrease the incidence of postoperative aortic stenosis and insufficiency, and whether it results in fewer operations.

	References

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1. Myers JL, Waldhausen JA, Cryan SE, Gleason MM, Weber HS, Bayler BG. Results of surgical repair of congenital supravalvar aortic stenosis J Thorac Cardiovasc Surg 1993;1055:281-288.
2. McGoon DC, Mankin HT, Vlad P, Kirklin JW. The surgical treatment of supravalvular aortic stenosis J Thorac Cardiovasc Surg 1961;41:125-133.
3. Doty DB, Polansky DB, Jenson CB. Supravalvular aortic stenosis, repair by extended aortoplasty J Thorac Cardiovasc Surg 1977;74:362-371.[Abstract]
4. Brom AG. Obstruction of the left ventricular outflow tractIn: Khonsari S, editor. Safeguards and pitfalls in operative technique. 1st ed.. Rockville, MD: Apsen Publis; 1988. pp. 276-280.
5. McAlpine WA. Heart and coronary arteries. New York: Springer-Verlag; 1975. pp. 24.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Seo, D. Articles by Kim, Y. Search for Related Content PubMed PubMed Citation Articles by Seo, D. Articles by Kim, Y. Related Collections Congenital - acyanotic