Ann Thorac Surg 2008;85:345-346. doi:10.1016/j.athoracsur.2007.04.080
© 2008 The Society of Thoracic Surgeons
How To Do It
Left Ventricular Outflow Tract Reconstruction for Annular Erosion Using a Polyester Graft
Paolo Masetti, MD,
Nicholas T. Kouchoukos, MD*
Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St. Louis, Missouri
Accepted for publication April 20, 2007.
* Address correspondence to Dr Kouchoukos, Missouri Baptist Medical Center, 3009 N Ballas Rd, Suite 360C, St. Louis, MO 63131 (Email: ntkouch{at}aol.com).
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Abstract
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A technique is presented for treatment of annular erosion using a polyester tube graft that is sutured to the left ventricular outflow tract below the area of erosion. The graft is then everted and sutured to a composite graft. Interposition polyester grafts from the coronary arteries are attached to the composite graft above the valve.
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Introduction
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Aortic annular abscess, with or without regurgitation around a native or replacement aortic valve, is a serious complication of aortic valve endocarditis; this occurs in almost a third of cases of valvular infection with vegetations or in the presence of multiple abscesses with paravalvular leakage. This process can result in annular erosion, with discontinuity between the ascending aorta and the mitral valve and adjacent left ventricular myocardium. In patients who have already had one or more operations on the aortic valve or the aortic root, or in those receiving chronic renal dialysis or long-term therapy with adrenal steroids, annular erosion, even in the absence of overt infection, can result in similar discontinuity.
Surgical treatment, consisting of insertion of a replacement valve or valved conduit into this weakened area, can result in uncontrollable bleeding and dehiscence of the prosthesis. Placement of the prosthesis deeply into the left ventricular outflow tract (LVOT), where suitable tissue to anchor the valve is present, may result in distortion of the mitral annulus with resulting regurgitation and LVOT obstruction.
Several techniques have been described to manage this condition. These include suturing a patch of synthetic graft or pericardium (autologous or bovine) over the eroded area with subsequent valve or root replacement [1, 2], insertion of an aortic root allograft, pulmonary autograft or xenograft [3–5], and suture of a tubed conduit of pericardium or polyester graft into the LVOT, followed by suturing of a composite graft to the upper edge of the tube, placement of interposition grafts between the composite graft and the origins of the coronary arteries, and suturing of the composite graft to the distal aorta [6, 7].
We present our technique using a polyester tube graft that is sutured circumferentially to the LVOT below the area of erosion. The graft is then everted and sutured to a composite graft. Interposition grafts from the coronary arteries are attached to the composite graft above the valve.
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Technique
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Standard cardiopulmonary bypass is used with aortic or peripheral arterial (ie, axillary or femoral) cannulation, and bi-caval or femoral venous cannulation with a two-stage cannula. After aortic clamping and administration of cold blood cardioplegia (ie, antegrade and retrograde), the native aortic valve tissue or the previously inserted aortic valve or composite graft is excised. The eroded area is extensively debrided to remove all necrotic or infected tissue (Fig 1A). The coronary arteries are mobilized if technically feasible, and the diameter of the LVOT is determined with a valve sizer. A tubular segment of collagen-impregnated, woven polyester aortic graft (Hemashield Gold; Boston Scientific Corp, Natick, MA) of comparable size is placed into the LVOT, and the superior edge is sutured to the mitral valve below the eroded area and the adjacent myocardium with a continuous 3-0 polypropylene suture (Fig 1B). Relatively large bites of ventricular myocardium and of the anterior leaflet are taken to assure a secure suture line. After completion of this suture line, segments of 8-mm or 10-mm collagen-impregnated polyester graft are sutured end-to-end to the aortic tissue surrounding the right and left main coronary arteries using 4-0 or 5-0 polypropylene sutures. Alternatively, segments of the saphenous vein can be sewn to the coronary ostia or to the distal coronary arteries. Cardioplegic solution can then be antegrade delivered into the coronary arteries to optimize myocardial protection.
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Fig 1. Technique of operation. (A) The eroded area was extensively debrided to remove all necrotic or infected tissue. (B) A tubular segment of collagen-impregnated, woven polyester aortic graft of comparable size was placed into the left ventricular outflow tract and the superior edge was sutured to the mitral valve below the eroded area and the adjacent myocardium with a continuous 3-0 polypropylene suture. (C) A composite graft containing a mechanical or stented bioprosthetic valve attached to a coated polyester graft was sutured to the rim of the tube graft with a continuous 4-0 polypropylene suture. The distal end of the composite graft was sutured to the distal ascending aorta or to a previously inserted polyester graft.
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The polyester tube is then everted from the LVOT and cut to an appropriate length (ie, 2 cm to 3 cm). A composite graft containing a mechanical or stented bioprosthetic valve attached to a coated polyester graft is sutured to the rim of the tube graft with a continuos 4-0 polypropylene suture (Fig 1C). A porcine aortic valve graft (Freestyle aortic root heart valve [Medtronic Inc, Minneapolis, MN]) can also be used. The coronary artery grafts are cut to the appropriate length, as short as possible, and sutured to openings in the aortic graft with 5-0 polypropylene sutures. The distal end of the composite graft is sutured to the distal ascending aorta or to a previously inserted polyester graft (Fig 1C). Cardiopulmonary bypass is discontinued after completion of rewarming and evacuation of air from the heart.
We have used this technique in 6 patients ranging in age from 25 years to 57 years. The Institutional Review Board of the Missouri Baptist Medical Center determined that the study was exempt from board approval under Code Federal Regulation 46.101(b)(4). Five of the 6 patients had previous aortic root or aortic valve replacement. Two of these 5 patients had endocarditis of a prosthetic valve and an aortic allograft valve, respectively. The remaining 3 patients had a false aneurysm at the annulus after root replacement with a composite graft, thrombotic obstruction of a mechanical aortic valve, and degeneration of an aortic root allograft with severe aortic regurgitation. Patient 6 had severe calcification of the aortic root with severe ostial stenosis of the coronary arteries and extensive annular and mitral valve calcification that precluded safe insertion of a mechanical valve in the annular position. The size of the tubular graft placed into the LVOT in the 6 patients ranged between 24 mm and 30 mm. A composite graft containing a St. Jude valve (23 mm, 25 mm, or 27 mm; St. Jude Medical, St. Paul, MN) was used in 5 patients and 1 patient received a 27-mm porcine aortic root heart valve. All patients survived the operative procedure. No patient required insertion of a permanent pacemaker. A postoperative echocardiogram of patient 6 demonstrated a widely patent LVOT below the prosthetic valve (Fig 2). There have been two late deaths at 15 months and 74 months resulting from renal failure and cardiac failure, respectively. The remaining 4 patients are alive and well 10 months to 63 months postoperatively.
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Fig 2. Postoperative echocardiogram of patient 6 demonstrating widely patent left ventricular outflow tract (LVOT) (left arrows) beneath the prosthetic valve (right arrow).
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Comment
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This technique is of particular value when destruction or severe distortion of the aortic annulus precludes safe placement of a rigid mechanical or bioprosthetic valve, and when insertion of a prosthesis would result in significant LVOT obstruction. In our experience, it has eliminated bleeding from the annular suture line and LVOT obstruction.
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References
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- Symbas PN, Vlasis SE, Zacharopoulos L, Lutz JF. Aortic-left ventricular discontinuity and aortic regurgitation from acute endocarditis South Med J 1982;75:1476-1478.[Medline]
- David TE. Surgical management of aortic root abscess J Card Surg 1997;12:262-269.[Medline]
- Donaldson RM, Ross DM. Homograft aortic root replacement for complicated prosthetic valve endocarditis Circ 1984;70(Suppl I):I178-I181.[Medline]
- Oswalt JD. Aortic infective endocarditis managed by the Ross procedure J Heart Valve Dis 1993;2:380-384.[Medline]
- Katsumata T, Vaccari G, Westaby S. Stentless xenograft repair of excavating aortic root sepsis J Card Surg 1998;13:440-444.[Medline]
- Aoyagi S, Fukunaga S, Tayama E, Hayashida N, Kawara T. Surgical treatment of prosthetic valve endocarditis with left ventricular-aortic discontinuity: Reconstruction of left ventricular outflow tract with a xenopericardial conduit J Heart Valve Dis 2001;10:367-370.[Medline]
- Jault F, Gandjbakhch I, Chastre, MD, et al. Prosthetic valve endocarditis with ring abscessesSurgical management and long-term results. J Thorac Cardiovasc Surg 1993;105:1106-1113.[Abstract]
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S. C. Stamou, M. C. Murphy, and N. T. Kouchoukos
Left ventricular outflow tract reconstruction and translocation of the aortic valve for annular erosion: Early and midterm outcomes
J. Thorac. Cardiovasc. Surg.,
August 1, 2011;
142(2):
292 - 297.
[Abstract]
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Abstract
Introduction
