Ann Thorac Surg 2008;86:1386-1387. doi:10.1016/j.athoracsur.2008.04.008
© 2008 The Society of Thoracic Surgeons
How To Do It
Transecting the Aorta to Close the Aortic Prosthetic Valve Paravalvular Space
Ivan C. Stojanovic, MDa,*,
Petar A. Milacic, MDa,
Sinisa P. Jagodic, MDb,
Ljiljana I. Jovovic, MD, PhDc,
Miroslava G. Gojnic, MD, PhDd,
Bosko P. Djukanovic, MD, PhDa
a Department of Cardiac Surgery, Institute for Cardiovascular Disease "DEDINJE," Belgrade, Serbia
b Department of Anesthesiology, Institute for Cardiovascular Disease "DEDINJE," Belgrade, Serbia
c Department of Cardiology, Institute for Cardiovascular Disease "DEDINJE," Belgrade, Serbia
d Department of Gynecology, Clinical Center of Serbia, Belgrade, Serbia
Accepted for publication April 3, 2008.
* Address correspondence to Dr Stojanovic, IKVB "DEDINJE," H.M. Tepica 1, Belgrade, 11000, Serbia (Email: stojivan{at}eunet.yu).
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Abstract
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The residual aortic prosthetic valve paravalvular space beneath the left coronary artery is very difficult and risky to repair. To improve visualization of this area, we transected the ascending aorta and mobilized both the aortic root and the left coronary artery from the surrounding tissue. Subsequently, we retracted the left coronary artery aside and pulled the posterior aortic root upwards. This maneuver has provided enough space for the safe placement of stitches and the closure of the paraprosthetic defect in this very delicate area.
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Introduction
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The residual space between the aortic valve prosthesis and the aortic annulus is a common problem in aortic valve surgery. Such a defect could be due to an incompletely seated prosthetic valve, faultily tied stitches, large stitch spacing, and so forth. A prosthetic valve should be examined when implanted, and a potential paraprosthetic space has to be repaired during the surgery to prevent paravalvular leakage afterwards. Depending on the anatomy and location, it is sometimes very difficult and risky to place the additional stitches for repairing such a defect. The area of particular concern is the aortic annulus beneath the left coronary artery. It is important not to damage the left coronary artery nor compromise its flow while the stitches are being placed. In this report, we describe a useful maneuver for repairing the paraprosthetic defect in the left coronary annulus area.
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Technique
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A 55-year-old woman underwent a double valve replacement due to aortic and mitral valve infective bacterial endocarditis. The valves were replaced with a mechanical bileaflet prosthesis using horizontal pledgetted interrupted mattress sutures. Because of the widespread vegetations we completely excised both leaflets and made debridment of the anterior mitral annulus close to the anterolateral commissure. Therefore, not much of the annulus tissue could be kept in this area, and the implanted mitral prosthesis pulled down and deformed the left coronary aortic annulus. After the aortic valve replacement, we found that the prosthesis did not sit correctly on the deformed left coronary annulus. A considerable paraprosthetic space was found beneath the left coronary artery. It was impossible to repair the defect from the outside of the aorta, so we decided to perform the following maneuver.
The aortic incision was extended posteriorly, completely dividing the ascending aorta from the aortic root. To mobilize the aortic root, we dissected it down to the annulus all the way around, particularly on the posterior side and from the pulmonary artery as well. Using extreme care, the left coronary artery was dissected and mobilized from the surrounding tissue. A rubber tape was used to loop the left coronary artery. That enabled us to safely pull the left coronary artery in the desired direction. The ascending aorta was dissected posteriorly as well. The posterior aortic root wall was grasped with a forceps and was pulled upwards and caudally to elevate and expose the posterior aortic annulus. At the same time, the left coronary rubber tape was pulled to the left (Fig 1). The additional space was obtained by rotating the aortic clamp along with the ascending aorta to the left, which opened enough space for repairing the defect. The horizontal pledgetted interrupted mattress sutures were placed from the outside of the aortic wall through the prosthesis sewing ring. We needed three stitches to close the gap. The aorta was closed in two layers with 5-0 polypropylene running suture. Intraoperative transesophageal echocardiography found no paravalvular leakage.
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Fig 1. To repair a paraprosthetic defect in the left coronary aortic annulus area, the aorta was transected, the left coronary artery was pulled to the left (arrow), and the posterior aortic root wall was grasped with a forceps and displaced upwards (arrow).
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Comment
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Numerous surgical techniques for closing the residual paravalvular spaces (leaks) have been described [1, 2]. Placing stitches from the outside of the aorta is a general principle of repairing the residual aortic valve paraprosthetic space. The access to the outer side of the left coronary aortic annulus is limited, due to the vicinity of the left coronary artery that is covering this area. This is why some surgeons propose the access to the area from the inside of the main pulmonary artery, right pulmonary artery, or left atrium [3]. Having an extensive experience in aortic surgery, we realized that by removing the ascending aorta we could obtain quite a comfortable space for the suture placing in the left coronary annulus area. Instead of removing the ascending aorta, we cut it completely and dissected both the root and the ascending aorta from the surrounding structures. Having liberated the left coronary artery from the surrounding tissue, we achieved enough mobility to pull it aside and safely place subcoronary stitches. We found this maneuver easy, safe, and useful, both for the closure of the residual left coronary paravalvular space during the aortic valve replacement or for the repair of paravalvular leakage in this area.
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References
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- Konstantinov IE, Franzen SF, Olin CL. Periprosthetic leaks and valve deschiscence: alternative methods of repair J Heart Valve Dis 1997;6:281-287.[Medline]
- Ersoy U, Pasaoglu I, Yilmaz M. Atez S. An alternative repair technique for aortic paraprosthetic leakage. Eur J Cardiothoracic Surg 1999;15:204-205.[Abstract/Free Full Text]
- Williams Jr TE, Fanning WJ, Cattaneo SM. Aortic paravalvular leaks: alternative suture placement strategy for the left coronary cusp Ann Thorac Surg 1995;59:243-244.[Abstract/Free Full Text]
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Abstract
Introduction
