Ann Thorac Surg 2007;84:1774-1776. doi:10.1016/j.athoracsur.2007.07.035
© 2007 The Society of Thoracic Surgeons
How To Do It
Valve-Sparing Replacement of the Noncoronary Sinus of Valsalva in Patients With a Bicuspid Aortic Valve
Alfredo Giuseppe Cerillo, MD*,
Pier Andrea Farneti, MD,
Massimiliano Mariani, MD,
Tommaso Gasbarri, MD,
Marco Solinas, MD,
Mattia Glauber, MD
Operative Unit of Cardiac Surgery, "G. Pasquinucci" Hospital, The Institute of Clinical Physiology, The National Research Council, Massa, Italy
Accepted for publication July 9, 2007.
* Address correspondence to Dr Cerillo, Operative Unit of Cardiac Surgery, "G. Pasquinucci" Hospital, The Institute of Clinical Physiology, The National Research Council, Via Aurelia Sud, Massa, 54100, Italy (Email: cerillo{at}ifc.cnr.it).
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Abstract
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Progressive dilatation of the aortic root and ascending aorta is frequent in patients with bicuspid aortic valve, and isolated dilatation of the noncoronary sinus has been reported. We describe our technique for the selective replacement of the noncoronary sinus of Valsalva in patients with bicuspid aortic valve.
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Introduction
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Progressive dilatation of the aortic root and ascending aorta is frequent in patients with bicuspid aortic valve (BAV) [1, 2]. Because this condition may predispose to aortic dissection, prophylactic root replacement has been proposed for patients with BAV undergoing aortic valve procedures or ascending aorta replacement [2–4].
The recognition that root dilatation may be limited to the posterior noncoronary sinus of Valsalva [1] has led us and others to selectively replace this sinus, thus avoiding the mobilization of the coronary arteries [2]. We briefly describe our technique for the selective replacement of the noncoronary sinus.
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Technique
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The operation is performed through a median sternotomy. The arterial cannula is positioned in the aortic arch. When the arch is dilated, femoral or axillary cannulation may be used. A single two-stage venous cannula in the right atrium allows the venous drainage, and a left ventricular vent is inserted from the right superior pulmonary vein.
After the institution of cardiopulmonary bypass, the aorta is carefully isolated and cross-clamped immediately beneath the origin of the innominate artery. Hyperkalemic warm blood cardioplegia is administered in the aortic root and then repeated every 20 minutes through a coronary sinus catheter. The dilated ascending aorta is removed up to the level of the sinotubular junction (STJ) (Fig 1a), and the different components of the aortic root are inspected. The aortic valve is sized, and the optimal dimension of the neo-STJ is determined. The appropriate Dacron vascular graft (DuPont, Wilmington, DE) is then opened on the surgical field. When needed, aortic valve repair may be performed at this stage.
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Fig 1. (a) The dilated ascending aorta is removed up to the level of the sinotubular junction. (b, c) The dilated sinus is removed leaving a 5-mm rim of aortic wall. (d) The patch is sized on the removed sinus of Valsalva, with the Dacron (DuPont, Wilmington, DE) fabric corrugation oriented longitudinally.
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We perform this operation when the posterior noncoronary sinus of Valsalva is consistently larger and has a thinner wall than the adjacent coronary sinus (Fig 1a). The quality and thickness of the coronary sinus of Valsalva wall should be assessed with particular care: in the presence of an even minimal doubt, we perform complete root replacement.
The dilated sinus is removed, leaving a 5-mm rim of aortic wall (Figs 1b and c). An appropriate sized, bullet-shaped Dacron patch is cut from the vascular prosthesis. The patch is sized on the removed sinus of Valsalva, with the Dacron fabric corrugation oriented longitudinally (Fig 1d). This allows a self-expanding neo-sinus, similar to the neo-sinuses that can be obtained with the Valsalva graft [5].
The Dacron patch (DuPont) is sutured to the aortic root with a double-armed 4-0 running polypropylene suture, starting from the nadir of the sinus. Both arms of the suture are continued up to the level of the STJ and tied (Fig 2a). The competence of the aortic valve is assessed again. Alternatively, when the effacement of the STJ is suspected to play a prominent role in the genesis of aortic regurgitation, the valve repair may be postponed to this stage of the operation and performed when the neo-STJ is completed. By eliminating one of the mechanisms possibly involved in the determinism of valve incompetence, this contrivance usually makes valve analysis easier.
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Fig 2. (a) The Dacron (DuPont, Wilmington, DE) patch is sutured to the aortic root with a double-armed 4-0 running polypropylene suture, starting from the nadir of the sinus. Both arms of the suture are continued up to the level of the sinotubular junction and tied. (b) The proximal anastomosis of the vascular graft is then performed with a double-armed 4-0 running polypropylene suture. (c) When the suture is complete and the neo-sinotubular junction has been fixed by the vascular prosthesis, the competence of the aortic valve is assessed again. (d) This self-expanding neo-sinus is similar to the neo-sinuses that can be obtained with the Valsalva graft. (See text for further explanation.)
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The proximal anastomosis of the vascular graft is then performed with a double-armed 4-0 running polypropylene suture (Fig 2b). The graft-to-graft portion of this suture may be reinforced with a strip of autologous pericardium. When the suture is complete and the neo-STJ has been fixed by the vascular prosthesis, the competence of the aortic valve is assessed again (Fig 2c).
Finally, the distal anastomosis of the vascular graft is performed with a double-armed 4-0 running polypropylene suture, air is removed from the heart, and the aortic cross clamp is removed. The patient is weaned from cardiopulmonary bypass, and the surgical result is carefully checked by an expert in echocardiography.
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Comment
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The BAV is probably one of the most common causes of aortic root enlargement in the current era [1]. In fact, there is unequivocal evidence that patients with BAV have an aortic medial fault, possibly due to abnormalities of fibrillin-1 and activation of the matrix metalloproteinases. For this reason, prophylactic root replacement has been suggested for patients with BAV and aortic root dilatation [1].
When the dilatation of the aortic root is confined to the noncoronary sinus of Valsalva, the selective replacement of this sinus may represent a good compromise, because even in the most experienced hands, the risk is double for root replacement compared with separate valve procedure and graft replacement of the ascending aorta [1]. We describe a simple technique for selective replacement of the noncoronary sinus of Valsalva that provides the additional benefit of obtaining a self-expanding neo-sinus, similar to the neo-sinuses that can be obtained with the Valsalva graft (Fig 2d) [5], and for remodelling the STJ. The potential advantages of the re-creation of the sinuses and of the STJ have been previously shown in finite element studies [6] and in vivo at echocardiography [7], and consist in the achievement of a smoother valve closure with a reduced stress on the valve leaflets, which is supposed to help to preserve the long-term valve function.
A potential limitation of our technique is that avoiding the replacement of the coronary sinus leaves intact a potential site for future dilatation; in fact, the idea that one should replace as much aortic tissue as possible is justified by the recognition that the aortic wall is intrinsically diseased in patients with BAV [1]. This notwithstanding, we are convinced that the coronary sinus of Valsalva is stabilized by the presence of a fixed noncoronary sinus, by the neo-STJ, and by the origin of the coronary arteries, and we believe that our technique leaves minimal space for recurrent aortic root dilatation. Other authors seem to share this opinion [2].
From March 2003 until now, 10 BAV patients with dilatation of the noncoronary sinus and of the ascending aorta have undergone selective replacement of the noncoronary sinus at "G. Pasquinucci" Hospital (Table 1). The in-hospital and short-term results of up to 4 years have been excellent. All patients are alive and well, there has been no reoperation, and only 1 patient has more than trivial residual aortic regurgitation.
In conclusion, we believe that this simple and expedient technique may represent a good alternative to full root replacement in patients with dilatation of the noncoronary sinus and that it allows the re-creation of a physiologic environment for the BAV.
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Acknowledgments
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We would like to thank Elaine Laws for her valuable help in manuscript preparation.
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References
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- Braverman AC, Güven H, Beardslee MA, Makan M, Kates AM, Moon MR. The bicuspid aortic valve Curr Probl Cardiol 2005;30:470-522.[Medline]
- Gerosa G, Pontarollo S, Liceto S, Di Marco F. An alternative technique for aortic root remodeling in patients with bicuspid aortic valve J Thorac Cardiovasc Surg 2007;133:249-250.[Free Full Text]
- Schäfers HJ, Aicher D, Langer F, Lausberg HF. Preservation of the bicuspid aortic valve Ann Thorac Surg 2007;83:S740-S745discussion S785–90.[Abstract/Free Full Text]
- Russo CF, Mazzetti S, Garatti A, et al. Aortic complications after bicuspid aortic valve replacement: long-term results Ann Thorac Surg 2002;74:S1773-S1776discussion S1792–9.[Abstract/Free Full Text]
- De Paulis R, De Matteis GM, Nardi P, Scaffa R, Colella DF, Chiariello L. A new aortic Dacron conduit for surgical treatment of aortic root pathology Ital Heart J 2000;1:457-463.[Medline]
- Grande-Allen KJ, Cochran RP, Reinhall PG, Kunzelmann KS. Recreation of sinuses is important for sparing the aortic valve: a finite element study J Thorac Cardiovasc Surg 2000;119:753-763.[Abstract/Free Full Text]
- De Paulis R, De Matteis GM, Nardi P, Scaffa R, Bassano C, Chiariello L. Analysis of valve motion after the reimplantation type of valve-sparing procedure (David I) with a new aortic root conduit Ann Thorac Surg 2002;74:53-57.[Abstract/Free Full Text]
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Abstract
Introduction
