Ann Thorac Surg 2009;88:2024-2025. doi:10.1016/j.athoracsur.2009.04.123
© 2009 The Society of Thoracic Surgeons
Case Reports
Replacement of Valve Prosthesis Within Aortic Composite Graft
Paul P. Urbanski, MD, PhD*
Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
Accepted for publication April 21, 2009.
* Address correspondence to Dr Urbanski, Herz- und Gefaess-Klinik, Salzburger Leite 1, Bad Neustadt, 97616, Germany (Email: p.urbanski{at}kardiochirurg.de).
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Abstract
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A 64-year-old man was referred for aortic valve re-replacement due to moderate-to-severe stenosis that developed 10 years after complete aortic root replacement using a stentless valve composite graft. He also had coronary heart disease and a mitral valve defect with predominant insufficiency. The patient underwent re-do surgery consisting of coronary artery bypass grafting, mitral valve replacement, and replacement of the valve prosthesis within the aortic conduit, which I believe is the first report of such a procedure.
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Introduction
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Use of biological valve prostheses is associated with an increased risk of reoperation due to valve deterioration. Because an aortic root re-replacement belongs to high-risk surgery [1, 2], it would be of utmost importance to facilitate this kind of surgery by providing the possibility of a valve re-replacement by leaving the root conduit untouched.
In 1998, a 54-year-old man with coronary heart disease and ascending aortic aneurysm combined with insufficiency of the bicuspid aortic valve underwent complete aortic root replacement with a stentless aortic valve composite graft and vein graft to the left anterior descending artery at our institution. Ten years after primary surgery, he suffered angina pectoris as well as incremental dyspnea, which ultimately resulted in the New York Heart Association functional class III. The cardiologic examination revealed a mitral valve defect with predominant severe insufficiency and mild stenosis (ie, a transvalvular mean gradient of 6 mm Hg) and moderate-to-severe aortic valve stenosis, with a mean gradient of 32 mm Hg, and an orifice area of 1.1 cm2. The coronary angiography showed severe stenosis of the right and left circumflex arteries, as well as a competent and unchanged vein graft to the occluded left anterior descending artery. The left ventricular ejection fraction was normal (62%). The logistic EuroSCORE was calculated at 19.48%.
The patient was reoperated on through a median sternotomy with the use of cardiopulmonary bypass and mild systemic hypothermia. For arterial return, a femoral artery was cannulated and myocardial protection was achieved with cold crystalloid cardioplegia. The mitral valve was replaced using a 33-mm Carpentier Edwards Perimount Plus prosthesis (Edwards Lifesciences, Irvine, CA), and two vein grafts were applied to the right and left circumflex coronary arteries. Aortic valve re-replacement was performed by transverse incision of the aortic graft just above the commissures of the stentless valve prosthesis. At the primary surgery, the stentless valve prosthesis (SPV Toronto; St. Jude Medical Inc, St. Paul, MN) was fixed to the vascular tube (InterGard; InterVascular, La Ciotat, France) along its upper edge and at the bottom with two continuous polypropylene sutures [3]. After cutting both sutures, the valve prosthesis was easily and completely removed (Fig 1). The aortic valve was replaced with a 23-mm Carpentier Edwards Perimount prosthesis (Edwards Lifesciences) and was sewed to the annulus with interrupted pledgeted mattress sutures of 2-0 braided polyester using a supra-annular technique, passing the sutures through the annulus from the ventricular side (Fig 2). The postoperative course was uneventful and the patient was able to be discharged from the hospital on postoperative day 12.
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Fig 1. Operative photographs showing: (A) the deteriorated stentless valve (SPV Toronto [St. Jude Medical Inc, St. Paul, MN]) inside the vascular tube (InterGard [InterVascular, La Ciotat, France]); and (B) removal of the valve prosthesis by cutting the suture between the valve and the tube; and (C) the valve view after its complete removal.
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Fig 2. Operative photographs showing (A) the passing of the pledgeted sutures for valve fixation through the annulus, and (B) the location of the pericardial valve prosthesis (Carpentier Edwards Perimount Plus [Edwards Lifesciences, Irvine, CA]) inside the vascular tube (InterGard [InterVascular, La Ciotat, France]).
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Comment
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Ten years ago, I proposed the self-assembling of the aortic valve composite grafts, of which the most important characteristics are: (1) placing the valve prosthesis inside the graft, leaving a rim of the Dacron tube beneath the valve prosthesis (InterVascular, La Ciotat, France) for anastomosing to the annulus, (2) implanting the graft supra-annularly by passing the sutures through the end of the Dacron tube rather than through a sewing ring of the valve prosthesis, and (3) reimplanting the coronary ostia end-to-side directly in the well-proven button-technique. These conduits offer a wide range of advantages (eg, the possibility of valve over-sizing; the ability to anastomose the conduit to an altered annulus; and especially in the case of biological valve prostheses, the potential facilitation of replacing them within the aortic conduit, if necessary) [3–5]. The stentless valve prostheses seemed to be very suitable substitutes to be re-replaced within the vascular tube; therefore, I preferred them for assembling the biological aortic composite grafts [6, 7].
During the surgery described, I had the occasion to prove the feasibility of valve re-replacement. This case confirmed that the replacement of the stentless valve prosthesis within the polyester tube is very easy in contrast to its replacement after subcoronary implantation within the native aorta or as an aortic root [8]. The complete covering of the outside wall of the stentless valve (SPV Toronto; St. Jude Medical Inc) with a polyester fabric may play a decisive role in this aspect. However, St. Jude Medical Company has decided to abandon the production of the stentless valves, inhibiting the ability of the surgical community to use this valuable and proven device. Nevertheless, it can be expected that the replacement of stented biological valves within the vascular tube would be similarly easy as the reported replacement of the stentless valve.
In conclusion, this case evidence confirms the possibility of simple and easy replacement of the valve prosthesis within a vascular graft and is a big step toward consideration of the biological valve composite graft as a device of choice for patients needing root replacement with biological substitutes.
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Acknowledgments
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The author would like to thank Mrs Melissa Lindner, Mrs Alexandra Metz, and Mrs Bianca Müller for preparing this article.
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References
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- Joudinaud TM, Baron F, Raffoul R, et al. Redo aortic root surgery for failure of an aortic homograft is a major technical challenge Eur J Cardiothorac Surg 2008;33:989-994.[Abstract/Free Full Text]
- Kirsch EWM, Radu NC, Mekontso-Dessap A, Hillion ML, Loisance D. Aortic root replacement after previous surgical intervention on the aortic valve, aortic root, or ascending aorta J Thorac Cardiovasc Surg 2006;131:601-608.[Abstract/Free Full Text]
- Urbanski P, Hacker W. Replacement of the aortic valve and ascending aorta with a valved stentless composite graft: technical considerations and early clinical results Ann Thorac Surg 2000;70:17-20.[Abstract/Free Full Text]
- Urbanski P. Complete aortic root replacement in patients with small aortic annulus Ann Thorac Surg 2002;73:725-729.[Abstract/Free Full Text]
- Urbanski P, Dinstak W, Frank St, Siebel A, Hacker R. Modified versus standard mechanical valved aortic conduit Asian Cardiovasc Thorac Ann 2005;13:53-57.[Abstract/Free Full Text]
- Urbanski P, Diegeler A, Siebel A, Zacher M, Hacker R. Valved stentless composite graft: clinical outcomes and hemodynamic characteristics Ann Thorac Surg 2003;75:467-471.[Abstract/Free Full Text]
- Urbanski P. New vascular graft for assembling the stentless valve composite graft Ann Thorac Surg 2007;84:1771-1773.[Abstract/Free Full Text]
- Borger MA, Prasongsukarn K, Armstrong S, Feindel CM, David TE. Stentless aortic valve reoperations: a surgical challenge Ann Thorac Surg 2007;84:737-743.[Abstract/Free Full Text]
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Abstract
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