Ann Thorac Surg 2008;85:2150-2152. doi:10.1016/j.athoracsur.2007.11.077
© 2008 The Society of Thoracic Surgeons
How To Do It
Right Coronary Sinus Fixation Through a Right Ventriculotomy for David's Procedure
Louis Labrousse, MDa,*,
Michel Montaudon, MD, PhDb,c,
Sheila Black, MDd,
Claude Deville, MDa
a Department of Cardiovascular Surgery, Hôpital Haut-Lévèque, Bordeaux Heart University Hospital, Bordeaux-Pessac, France
b Department of Radiology, Hôpital Haut-Lévèque, Bordeaux Heart University Hospital, Bordeaux-Pessac, France
d Department of Anaesthesiology, Hôpital Haut-Lévèque, Bordeaux Heart University Hospital, Bordeaux-Pessac, France
c Laboratory of Anatomy, University Victor Segalen, Bordeaux, France
Accepted for publication November 28, 2007.
* Address correspondence to Dr Labrousse, Service de Chirurgie Cardio-Vasculaire, Hôpital Haut-Lévèque, Avenue de Magellan, 33 604, Pessac-Cedex, France (Email: louis.labrousse{at}chu-bordeaux.fr).
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Abstract
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A key element to the success of aortic valve reimplantation (David's procedure) is the position of the aortic annulus in the Dacron tube (DuPont, Wilmington, DE). The variable level of the right ventricular insertion can cause technical difficulties, especially when the right ventricular insertion occurs above the aortic annulus. To resolve this issue, a technical adjunct is described using a right superior ventriculotomy. This technique allows perfect aortic annulus containment, avoids any rocking motion of the margin of the right coronary cusp, and affords the procedure better long-term durability.
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Introduction
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In the last decade, valve-sparing aortic root replacement with aortic valve reimplantation [1] has become the procedure of choice in the treatment of abnormal dilatation of the sinuses of Valsalva. This procedure is more technically complex than the classic Bentall procedure but may be justified on the condition that repeat operations are minimal [2, 3]. To ensure this low rate of redo operation, however, two essential technical features must be achieved. The first is perfect circumferential aortic annulus containment by the proximal part of the Dacron tube (DuPont, Wilmington, DE) to avoid long-term recurrence of annulus dilatation. The second is the maintenance of aortic cups geometry with a margin line above the native aortic annulus level, defined as effective cusp height [4], and without cusp distortion.
Once both criteria are achieved for the left and the noncoronary sinus, for the right coronary sinus the surgeon must contend with the superior and proximal insertion of the anterior wall of the right ventricle on the fibrous skeleton of the heart. From our experience and in anatomic specimens (Figs 1 and 2),
it appears that at this level the insertion position is variable. Achieving right sinus dissection and suture position from the left ventricular outflow through the aortic annulus tract is easy and efficient if the right ventricular insertion is below the aortic annulus. When the insertion is over the aortic annulus, however, surgical dissection tends to stop before the annulus level and a thick excess of ventricular tissue is left along the aortic annulus. As a consequence, if the Dacron tube is positioned above the aortic annulus level, containment of the annulus is less efficient and a central rocking motion may occur on the margin of the right cusp when sutures are tied. This cusp prolapse, or more precisely, a low effective height of the margin line [4], is associated with initially acceptable regurgitation but a higher long-term failure rate [5]. Our method avoids these two problems by systematically using a right superior ventriculotomy when the right ventricular insertion is above the aortic annulus.
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Technique
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The main part of the procedure is performed as described by David and colleagues [1]. Both caval veins are cannulated with tapes tied around them. Once the aorta is clamped and the heart arrested, the ascending aorta is transected at the sinotubular junction and the aortic valve mobilized by dissecting the coronary sinus from the surrounding tissue. Right and left coronary ostia are isolated and prepared for future reattachment. The external part of the aortic annulus is easy to reach on the noncoronary and left coronary sinus. Sinus tissue is then excised leaving a 3- to 4-mm margin for swelling of the valve into the Dacron tube.
The right ventricle is then separated from the left ventricular outflow. If the insertion of the right ventricular wall is above the level of the aortic annulus, then a right ventriculotomy is created 2 to 3 mm outside the aortic annulus (Fig 3). This incision allows sutures to pass through the aortic annulus and the adjacent right endocardial layer in a perfect horizontal pattern (Fig 3). Usually, this right ventriculotomy is used for the 3 to 4 sutures around the nadir of the right coronary sinus.
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Fig 3. (Right) Right ventricular incision and sutures passed from the left ventricular outflow (left) through the aortic annulus to the internal part of the right ventricular insertion.
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The Dacron tube is positioned and the sutures are tied with a Hegar's dilatator inside the aortic annulus [6]. The ventriculotomy is closed with 4 to 6 pledgeted U stitches (Fig 4) from the right ventriculotomy to the proximal border of the Dacron tube. The procedure ends as described by David and colleagues [1], and the position of the aortic annulus below the Dacron tube is confirmed using postoperative transesophageal echocardiography (Fig 5).
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Fig 5. Postoperative transesophageal echocardiography. The Dacron tube (DuPont, Wilmington, DE) is below the aortic annulus at the septal level (arrow indicates the aortic annulus).
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Comment
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This technical adjunct for aortic valve reimplantation procedure is a useful method of ensuring circumferential containment of the aortic annulus by the Dacron tube and preventing right aortic cusp prolapse due to the procedure itself. We found that about 20% (12 of 51) of our patients needed this technical adjunct. In our experience, bleeding does not arise from the ventriculotomy. Indeed, performing a ventriculotomy systematically in this situation is easier and safer to repair than an unrecognized ventricular tear after release of the aortic clamp.
Finally, neither abnormal cardiac enzyme elevation nor right ventricular dysfunction was observed during the postoperative course. None of our patients died during the postoperative course. Postoperative and mid-term echocardiography showed little to no (
grade 1) aortic regurgitation, and no patient required repeat operation.
The theoretic advantages of David's procedure—no anticoagulation drugs, fixation of the left ventricular outflow tract/aortic annulus, repair of aortic regurgitation—have led to this procedure being proposed for almost all patients with aortic root aneurysm. However, this is a technically demanding procedure associated with potential aortic cusp and annulus geometry distortion as well as reduced physiologic motion of the aortic cusps [7]. The long-term need for a repeat procedure is still to be evaluated but is expected to be low, assuming perfect annulus containment and normal effective height of the aortic cups [4].
In conclusion, the main advantages of this technical adjunct are that annulus containment is more efficient in cases where right ventricular insertion is above the aortic annulus and that it prevents right coronary cusp prolapse. Twenty percent of our patients have benefited from this technical adjunct with excellent clinical results.
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References
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- David TE, Feindel CM, Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm J Thorac Cardiovasc Surg 1995;109:345-351.[Abstract/Free Full Text]
- David TE, Feindel CM, Webb GD, Colman JM, Armstrong S, Maganti M. Long-term results of aortic valve-sparing operations for aortic root aneurysm J Thorac Cardiovasc Surg 2006;132:347-354.[Abstract/Free Full Text]
- Kallenbach K, Karck M, Pak D, et al. Decade of aortic valve sparing reimplantation: are we pushing the limits too far? Circulation 2005;112(9 suppl):I253-I259.[Medline]
- Schafers HJ, Bierbach B, Aicher D. A new approach to the assessment of aortic cusp geometry J Thorac Cardiovasc Surg 2006;132:436-438.[Free Full Text]
- Pethig K, Milz A, Hagl C, Harringer W, Haverich A. Aortic valve reimplantation in ascending aortic aneurysm: risk factors for early valve failure Ann Thorac Surg 2002;73:29-33.[Abstract/Free Full Text]
- Svensson LG. Sizing for modified David's reimplantation procedure Ann Thorac Surg 2003;76:1751-1753.[Abstract/Free Full Text]
- Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root J Thorac Cardiovasc Surg 1998;115:1080-1090.[Abstract/Free Full Text]
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Abstract
Introduction
