Ann Thorac Surg 2009;88:1705-1707. doi:10.1016/j.athoracsur.2009.02.016
© 2009 The Society of Thoracic Surgeons
How To Do It
A Modified Composite Valve Dacron Graft for Prevention of Postoperative Bleeding From the Proximal Anastomosis After Bentall Procedure
Liang-Wan Chen, MD*,
Xiao-Fu Dai, MD,
Xi-Jie Wu, MD
Department of Cardiac Surgery, Union Hospital, Fuzhou, China
Accepted for publication February 9, 2009.
* Address correspondence to Dr Chen, Department of Cardiac Surgery, Union Hospital, Fuzhou, Fujian, 350001, China (Email: chenliangwan{at}tom.com).
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Abstract
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Bleeding is one of the most devastating complications of the Bentall procedure. We describe a simple, modified composite valve Dacron (DuPont, Wilmington, DE) graft to prevent bleeding from the proximal anastomosis between the graft and aortic annulus. The composite graft was modified by adding a short skirt of Dacron tube to a standard composite graft root. After the proximal end of the modified composite graft was implanted in the aortic annulus, the short skirt of Dacron tube was sewed to the remaining native aortic wall to wrap the proximal graft and aortic annular anastomosis. Our initial application of the modified composite graft demonstrated that this modified composite graft is an easy and effective way to prevent bleeding from the proximal anastomosis after the Bentall procedure.
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Introduction
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Since it was first described in 1968, the Bentall and De Bono aortic root replacement with a composite valve Dacron (DuPont, Wilmington, DE) graft has become the gold standard in the treatment of combined aortic valve and root diseases [1]. Bleeding is still one of the most devastating complications, however [2].
The new generation of Dacron grafts and the various technical modifications that were aimed to reduce tension on the button coronary anastomoses have effectively prevented bleeding from the anastomoses between the graft and coronary anastomoses [3, 4]. However, very few technical modifications to prevent bleeding from the proximal aortic annular anastomosis have been reported. Therefore, in this report we present a simple modification of the standard Dacron composite valve by adding a Dacron skirt to wrap the proximal anastomosis for preventing bleeding after the Bentall procedure.
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Technique
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Modification of the Standard Composite Valve Dacron Graft
After selection of a properly sized standard composite valve Dacron graft (Boston Scientific, Natick, MA), a 1- to 1.5-cm Dacron graft tube was transected down from the distal end of the composite graft. This transected, short Dacron tube was turned outward and placed around the root of the composite graft, with the lower edge of the short tube 0.3 to 0.5 cm above the bottom border of the composite graft. After a continuous 4-0 polypropylene suture was used to attach the lower edge of the short tube around the composite graft wall (Fig 1A), three opening points were made longitudinally (two-thirds of the skirt width) from the upper edge towards the lower edge at points corresponding to three suture markers of the sewing ring of the prosthetic valve. The upper edge was pulled downward and outward, forming a skirt around the graft (Fig 1B), resulting in a new modified composite valve Dacron graft (DuPont) being constructed, called the skirted composite valve Dacron graft.
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Fig 1. (A) The composite graft was modified by adding a short skirt of Dacron tube to a standard composite graft root. (B) The upper edge was pulled downward and outward, forming a skirt around the graft.
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Surgical Technique
We followed the standard surgical steps described by Bentall and De Bono for the Bentall procedure [1]. The heart was arrested and the aorta was completely transected just above the sinotubular junction. After resection of the aortic cusps, the coronary buttons were constructed with a 0.5- to 0.8-cm-diameter cuff of aortic wall and mobilized over a short length to facilitate reimplantation. The native aortic root was excised, leaving about 0.5 to 0.8 cm of residual aortic wall above to the annulus. A series of U stitches of 2-0 braided suture with pledgets were placed within the aorta and passed below the aortic valve annulus (from aortic to ventricular side), and then through the prosthetic valvular sewing cuff of our modified composite graft.
The modified composite graft was pulled down to the aortic annulus and the sutures were tied (Fig 2A). The skirt was then trimmed to match the margin of native residual aortic wall, and a proper length of the skirt at each circumferential point was selected to minimize the perianastomosis space between the skirt and the residual native aortic wall. Then, a continuous 4- polypropylene suture was used to sew the skirt to the residual aortic wall to wrap the proximal anastomosis (Fig 2B).
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Fig 2. (A) After the modified composite graft was implanted on the aortic anulus and the sutures were tied, (B) an anastomosis between the skirt and the residual aortic wall was made to wrap the proximal anastomosis.
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The coronary buttons were reimplanted to the modified composite graft without any tension. The distal end of the modified composite graft was anastomosed to the distal ascending aorta.
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Comment
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From July 2006 through May 2008, 39 patients underwent the Bentall procedure at our department. In the first 24 consecutive patients (group 1), 17 with aortic root degenerative aneurysms and 7 with acute aortic dissections, the standard composite valve Dacron graft (DuPont) was used. In the next 15 patients (group 2), 9 with aortic root degenerative aneurysms and 6 with acute aortic dissections, our modified composite graft was used. With the use of our modified composite graft in group 2, we did not encounter any difficult bleeding from the proximal anastomosis after the clamps were released, and no patient required a reopening of the chest to correct excessive postprocedural bleeding. We have observed a 51% reduction in postoperative bleeding, from 846.4 ± 48.9 mL in group 1 to 429.3 ± 38.4 mL in group 2 (p < 0.01). Blood transfusion was reduced from 4.08 ± 0.27 U in group 1 to 2.06 ± 0.25 U in group 2 (p < 0.01). No group 2 patients died, and all were discharged from the hospital without complications. The echocardiographic examination before discharge showed no hematoma or false aneurysm in group 2 (Fig 3).
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Fig 3. (A and B) A postoperative echocardiographic examination showed no hematoma or false aneurysm around the proximal anastomosis. (A) Parasternal long axis view of left ventricle, (B) parasternal short axis view of left ventricle (the aortic valve level).
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Some surgeons have applied a tight wrap to the composite graft, using residual aneurysmal aortic wall or autologous pericardium to wrap the proximal anastomosis, or have created an anastomosis between the perigraft space and right atrial appendage to manage bleeding from the proximal anastomosis [4]. However, this technique could lead to formation of pseudoaneurysm, compression of the neoaorta by perigraft hematoma in the supravalvular position, and persisting aortic–right atrial shunt [5]. The modified composite graft presented in this study was designed to avoid these complications. The perianastomosis space was minimized by control of the length of the Dacron skirt (Boston Scientific) at each circumferential point, and coronary buttons were excluded from this space. Therefore, our modified technique significantly reduced the risk of complications caused by traditional technique of wrapping the graft.
In the early practice with our modified technique, fibrin glue was injected into the perianastomosis space to achieve a more hemostatic anastomosis and a smaller perianastomosis space. A theoretic risk of using the glue is that it might leak into the left ventricle and inside the modified composite graft through the potential suture holes during the early sealing process, which could result in glue embolization. However, no embolization was observed in our patients. In the most recent 5 patients who underwent the Bentall procedure with our modified composite grafts, without using biologic glue, the amount of postoperative bleeding did not increase (402.4 ± 87.6 mL) and the number of blood transfusions required did not increase (2.60 ± 0.54 U). This preliminary result suggests that glue injection may not be necessary with our modified technique, mainly because our secondary wrap is hemostatic.
Potential problems of coronary anastomosis tension and difficulty in reimplanting coronary ostium could occur when our modified composite graft is used for a nondilated aortic root such as dissecting aortic aneurysm. It is important that the corresponding holes made in the composite graft for reimplantation of the coronary buttons are above the attachment level of the skirt and higher than in the classic button technique to avoid tension on the anastomosis. The attaching level of the skirt should not be higher than 0.5 cm from the aortic annulus. After detachment of the coronary buttons, if the residual aortic wall proximal to the coronary ostium is not high enough to contact the skirt, it will cause difficulty in the anastomosis. To avoid this drawback, we made the corresponding portions of the skirt long enough to allow no tension on the anastomosis between the residual aortic wall and the skirt. With these technical attentions in our patients without a dilated aortic root, we did not find that the skirt made coronary anastomosis more difficult or required greater mobilization of coronary buttons to avoid tension of the coronary anastomosis.
In conclusion, we present a simple modification of the Dacron composite aortic valve to effectively prevent bleeding from the proximal anastomosis after the Bentall procedure.
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References
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- Bentall H, De Bono A. A technique for complete replacement of the ascending aorta Thorax 1968;23:338-339.[Abstract/Free Full Text]
- Lewis CT, Cooley DA, Murphy MC, et al. Surgical repair of aortic root aneurysms in 280 patients Ann Thorac Surg 1992;53:38-46.[Abstract/Free Full Text]
- Vitale N, Owens WA, Hamilton JR, et al. Early results with carbo-seal composite valve conduit for aortic root replacement J Heart Valve Dis 1999;8:80-84.[Medline]
- Cabrol C, Pavie A, Mesnildrey P, et al. Long-term results with total replacement of the ascending aorta and reimplantation of the coronary arteries J Thorac Cardiovasc Surg 1986;91:17-25.[Abstract]
- Svensson LG, Crawford ES, Hess KR, et al. Composite valve graft replacement of the proximal aorta comparison of techniques in 348 patients Ann Thorac Surg 1992;54:427-439.[Abstract/Free Full Text]
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Abstract
Introduction
