Ann Thorac Surg 2009;88:1026-1028. doi:10.1016/j.athoracsur.2008.10.074
© 2009 The Society of Thoracic Surgeons
How To Do It
Aortic Valve-Sparing Operations: Dealing With the Coronary Artery That is Too Close to the Aortic Annulus
Amir M. Sheikh, FRCS(CTh), MBBS*,
Tirone E. David, MD
Peter Munk Cardiac Centre of Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
Accepted for publication October 23, 2008.
* Address correspondence to Dr Sheikh, 114 Rowlands Ave, Pinner, Middlesex, HA5 4AP, United Kingdom (Email: amsheikh10{at}hotmail.com).
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Abstract
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During aortic root surgery, one of the coronary ostia is sometimes found to lie too close to one of the commissures to allow its safe detachment as a button while still preserving the native aortic valve. In the past, this has prevented aortic valve-sparing root replacement in cases of aortic root aneurysm. We describe a technique pertaining to the reimplantation method of aortic valve-sparing root replacement to deal with such a displaced coronary artery.
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Introduction
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Aortic valve-sparing operations are increasingly used to repair aortic root aneurysms. There are basically two techniques of aortic valve-sparing operations: (1) reimplantation of the aortic valve [1] and remodeling of the aortic root [2, 3]. The reimplantation method seems to be less likely to result in annular dilatation and enjoys great freedom from recurrent aortic insufficiency, and as a consequence, greater freedom from reoperation in the long term [2, 4, 5]. The reimplantation technique, described by David and Feindel [1] in 1992, re-suspends the aortic annulus and the attached cusps within a Dacron graft (DuPont, Wilmington, DE) in a manner to allow restoration of the subcommissural triangles to a more acute angle, thereby restoring valve competence. The coronary arteries are reimplanted as buttons. However, displacement of the coronary arteries may result in the origin of one coronary artery being too close to the aortic annulus or commissural area, so as to prevent its safe detachment with enough aortic sinus wall around it to allow for reimplantation as a button. This is particularly common in patients with a bicuspid aortic valve and an aortic root aneurysm. We describe a technique that allows aortic valve-sparing to be accomplished in cases in which one coronary ostium is too close to the commissure to allow its safe detachment and reimplantation using the conventional button technique. We have used this technique for both left and right coronary arteries in 5 patients with aortic root aneurysm (3 who had a bicuspid aortic valve and 2 who had a tricuspid aortic valve).
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Technique
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In a patient with an aortic root aneurysm, after determining that the native valve cusps are satisfactory to preserve the valve, the ascending aorta and sinuses of Valsalva are excised, leaving a rim of approximately 5 mm above the aortic annulus. The nondisplaced coronary artery is fashioned as a button and dealt with as is normally done. However, the displaced coronary artery is left in situ, and the excision of the aortic tissues is tailored so as to leave 5 mm of aortic sinus wall around its ostium (Fig 1). The subannular sutures (horizontal mattress 2-0 braided polyester) are placed in a horizontal plane below the lowest level of the aortic annulus. After selecting a suitably-sized Dacron graft (DuPont), a vertical slit of approximately 2 to 3 cm is made in its proximal end, to accommodate the displaced coronary, once the graft is anchored down. The subannular sutures are put through the proximal rim of the graft. The graft is lowered down to the subannular plane as normal, after pulling the aortic commissures inside the graft. The in situ coronary artery composite button now sits in the groove fashioned in the graft. This coronary artery is examined to make sure that it has not been kinked or compressed by the Dacron, and if necessary the slit is extended to ensure the coronary button is sitting without any compression from the graft whatsoever. The graft is tied down, so anchoring it to the subannular plane. Using pledgetted horizontal mattress polypropylene sutures all three commissures are re-suspended inside the tube graft, after determining their correct height and alignment. Using continuous 4/0 polypropylene sutures, the aortic annulus and remnant sinuses are re-suspended within the tube graft as usual.
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Fig 1. (Left) The aortic root is shown after being prepared. The ascending aorta has been excised. The right coronary artery button, which is not displaced, has been prepared as normal. The left coronary artery button, which is too close to the left, noncoronary commissure has been left in situ. (Center) The subannular mattress sutures have been placed. The Dacron graft (DuPont, Wilmington, DE) has a slit cut into the proximal end to accommodate the in situ coronary artery. (Right) The Dacron graft has been tied down to the subannular plane. The slit in the Dacron graft has been further trimmed to create an orifice to house the in situ coronary artery. The commissures and the valve annulus incorporating the in situ coronary artery have been re-suspended inside the Dacron conduit. The remaining coronary button is reimplanted as normal.
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The edges of the slit fashioned in the tube graft are then trimmed to create an orifice for the displaced coronary artery (Fig 2). The aortic sinus around the orifice of the artery is then sutured to the Dacron graft by continuing the polypropylene suture that was used to re-suspend the adjacent commissure. After completing the upper and lateral border of this composite button, and when reaching its lower border, the remaining aortic annulus and sinus remnants are re-suspended as usual.
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Fig 2. (A) A bicuspid aortic valve is shown after the ascending aorta has been opened, with the aortic cross clamp visible at the bottom of the picture. The left coronary artery ostium, in which a plastic cardioplegia cannula is sited (arrow), can be seen lying immediately next to the commissure (arrowhead). (B) After tying down the Dacron graft (DuPont, Wilmington, DE) to the subannular plane and re-suspending the commissures, an orifice is being created in the graft to accommodate the left coronary artery, commissure composite button. (C) The appearance of the left coronary artery composite button inside the Dacron graft. The polypropylene suture re-suspending the adjacent commissure is continued along the upper and lateral border of the left coronary artery button, thereby reimplanting it. When reaching the lower lateral border of the button, the suture is continued, so as to re-suspend the aortic annulus, which is routinely done.
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The other coronary artery is reimplanted using the traditional button technique with continuous 5-0 polypropylene suture. Neosinuses are then created by plicating a small portion of the Dacron in each sinus at the level of the commissures. Valve competence is tested by clamping the distal end of the graft and delivering cardioplegia under high pressure into the neo-aortic root, and checking for ventricular distension. The distal aortic anastomosis is completed using 4-0 polypropylene. In the absence of arch replacement, the Dacron graft is anastomosed directly to the distal ascending aorta. If arch replacement has been performed, the root graft is anastomosed to the arch graft.
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Comment
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Aortic valve-sparing operations are a valuable technique in patients with aortic root aneurysms and normal aortic cusps. Encountering a coronary artery ostium too close to a commissure requires a modification of the technique as described in this article. This problem was encountered in 5 patients among 274 aortic valve-sparing operations for aortic root aneurysm. Three patients had a bicuspid aortic valve, and the left coronary artery in 1 patient and the right coronary artery in 2 patients were left in situ. Two patients had a tricuspid aortic valve and in both the left coronary artery was too close to the commissure. Three of these 5 patients had Marfan's syndrome. All cases were successfully dealt with using the technique we described.
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References
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- David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta J Thorac Cardiovasc Surg 1992;103:617-621.[Abstract]
- David TE, Armstrong S, Ivanov J, Feindel CM, Omran A, Webb G. Results of aortic valve-sparing operations J Thorac Cardiovasc Surg 2001;122:39-46.[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]
- De Oliveira NC, David TE, Ivanov J, et al. Results of surgery for aortic root aneurysm in patients with Marfan syndrome J Thorac Cardiovasc Surg 2003;125:789-796.[Abstract/Free Full Text]
- David TE, Ivanov J, Armstrong S, Feindel CM, Webb GD. Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta Ann Thorac Surg 2002;74:S1758-S1761.[Abstract/Free Full Text]
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Abstract
Introduction
