Ann Thorac Surg 2009;88:2047-2049. doi:10.1016/j.athoracsur.2009.02.100
© 2009 The Society of Thoracic Surgeons
How To Do It
Modification of the David Procedure for Reconstruction of Incompetent Bicuspid Aortic Valves
Farhad Bakhtiary, MD, PhD*,
Nadejda Monsefi, MD,
Maria Trendafilow,
Thomas Wittlinger, MD, PhD,
Mirko Doss, MD, PhD,
Anton Moritz, MD, PhD
Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt–Main, Germany
Accepted for publication February 13, 2009.
* Address correspondence to Dr Bakhtiary, Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor Stern Kai 7, Frankfurt-Main, 60590, Germany (Email: farhad{at}bakhtiary.de).
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Abstract
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The David procedure was described primarily to treat tricuspid valves. The asymmetry of the bicuspid root asks for modifications to achieve a competent bicuspid valve. The most common feature of the bicuspid valve is the presence of left and right coronary rudimentary cusps. In this case usually the base of the noncoronary cusp is displaced toward the left ventricular outflow tract. The uneven plane of this type of bicuspid aortic annulus has to be compensated for when a rigid prosthesis is wrapped around the aortic root. We describe the modification of the David technique in 14 patients who underwent a valve-sparing aortic root replacement in presence of a bicuspid valve. This technique increases the coaptation surface and provides reliable early and mid-term competence of the reconstructed bicuspid aortic valves.
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Introduction
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Valve repair for aortic insufficiency may provide an alternative to aortic valve replacement in selected patients. Advantages of aortic valve repair in comparison with aortic valve replacement include avoidance of anticoagulation and prosthetic valve-related complications. David and associates [1] described an aortic valve-sparing procedure with reimplantation of the valve within a prosthetic vascular graft in the early 1990s. This article describes our experience with the modification of the David procedure, particularly in patients with a bicuspid aortic valve.
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Technique
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Access to the heart was gained through a median sternotomy (7 patients through a partial upper sternotomy, 7 patients through a total sternotomy). We routinely used aortoatrial cannulation for extracorporeal circulation, antegrade and retrograde cold blood cardioplegia, CO2 insufflation of the operative field, and moderate hypothermia (32°C). The aortic valve was approached through a transverse aortotomy. After the placement of three stay sutures, the bicuspid valve was examined. The most common appearance of bicuspid valves is the fusion of the left and right coronary rudimentary cusps (Fig 1). In this case the base of the noncoronary cusp is displaced down into the left ventricular outflow tract. The uneven plane of the annulus of bicuspid valves has to be compensated for when a rigid prosthesis is wrapped around the aortic root.
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Fig 1. Intraoperative view of a bicuspid aortic valve after resection of the aortic wall. The pledget-armed stay sutures are at the tip of the true commissures. The forceps are showing the fused aortic valve leaflet.
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The aortic wall remnants are trimmed to a rim of 5 to 7 mm, and the remaining root is dissected off adventitia down to the annular plane. In most cases the annulus is not severely dilated, and simple sizing of the annulus gives the measure for the size of the prosthesis. As we create neosinuses in the prosthesis, 7 mm of diameter are added to the desired annular diameter [2]. A Dacron vascular prosthesis (DuPont, Wilmington, DE) is then trimmed, and a tongue-shaped extension is created to compensate for the deeper position of the noncoronary base. The area of the muscular septum is compensated for by using a scalloped incision. Then the positions of the true commissures are marked at the prosthesis. Their position varies between a 120° or more (up to 180°) spacing. The prosthesis is constricted at the base of the true commissures with a triangular stitch that crimps the prosthesis in circumference and height, thereby creating the base of the neosinuses. In the area of the pseudo commissure, this stitch is placed with a lesser extent of constriction. Then the usual subannular stitches with 4.0 Ethibond (Ethicon, Somerville, NJ) are placed. As we described for the conventional repair of bicuspid valve [3, 4], the raphe is mobilized and thickened closing edges of the leaflets are shaved, and a patch of glutharaldehyde-fixed autologous pericardium is fashioned and sewn to the free edge of the fused leaflet with a 5.0 Cardionyl running suture (Peters Laboratorys, Bobigny, France) (Fig 2). At completion of the suture line of the patch, the last stitches are placed just above the commissures and slightly deviated toward the neighboring cusp. This is done to safeguard the coaptation of the leaflets at this level.
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Fig 2. After mobilizing the raphe and shaving of thickened leaflet edges, a patch of glutaraldehyde-fixed autologous pericardium is fashioned and sewn to the free edge of the fused leaflet with a running suture.
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The pledget-armed stay sutures at the tip of the commissures are pulled through the prosthesis. The subannular sutures are passed through the base of the prosthesis and the prosthesis is tied in place (Fig 3). Then the tips of the commissures are positioned within the prosthesis to match the geometry of the reconstructed valve. Tension is put on the commissures, but not on the prosthesis. The commissural sutures are passed at corresponding height through the prosthesis, but taking more prosthesis width to constrict this area to recreate a sinotubular ridge when tying. For complete restoration of the sinuses, an additional triangular stitch is placed outside just below the tip of each commissure, constricting circumference and height to create a sinus bulge [2]. The aortic wall remnants are then sewn to the prosthesis with running 4.0 Prolene mattress sutures (Ethicon).
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Fig 3. The aortic graft is trimmed to match the displacement of the noncoronary base toward the left ventricular outflow tract. Sutures are passed through the aorta and the graft in the usual manner.
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By approximating the tips of the commissures, the leaflets free edges are relatively elongated and tend to sag into the outflow tract. In most cases, geometric reconstruction of the aortic valve is completed by plication of the free edge of the nonfused leaflet with a 5.0 Cardionyl u-stitch (Peters Laboratorys) and another figure-eight stitch across the closing edge.
The procedure is completed in the usual way by re-implanting the coronary ostia and performing the distal graft to aorta anastomosis (Fig 4).
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Fig 4. Completed repair showing the preserved asymmetry of the aortic root and the bulge of the neosinuses.
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Tables 1 and 2
summarize patient characteristics and clinical outcome. Overall survival was 100%. The degree of aortic regurgitation was none to trivial for all patients at last follow-up. There was no echocardiographic evidence of valve incompetence. We observed neither a case of endocarditis nor any neurologic event. The mean effective orifice area (EOA) was 2.9 ± 1.2 cm2. Mean aortic gradients were 5.2 ± 2.6 mm Hg, and the mean height of coaptation surface was 12.3 ± 3.1 mm.
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Comment
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Reimplantation of the aortic valve is a complex operation due to the fact that the aortic valve and the aortic root act as a geometric and functional unit [1]. Aortic valve incompetence may develop as a consequence of ascending aortic or aortic root aneurysm by spreading the commissures or annular dilatation [2]. In bicuspid aortic valves (BAV), prolapse of the fused cusps is seen as a frequent cause of failure. Sparing the aortic valve in selected cases of aortic insufficiency may be a reliable alternative to mechanical valve replacement. One of the major causes of aortic regurgitation is BAV [3], which seems to predominantly affect the young population [5] in whom one is reluctant to use a heterograft valve or to expose the patient to the risk of anticoagulation. It is not surprising that BAV repair is increasingly considered a reasonable option [2, 3, 5].
In large clinical series, excellent early results were reported for bicuspid repair [3, 5]. However, midterm results show a significant rate of reoperations within the first 5 years [5]. Apart from triangular cusp resection, no specific risk factor for failure was identified. With a modification of the technique by augmenting the fused leaflet with a pericardial patch, we were able to eliminate the risk of intraoperative revision and of reoperations at midterm [4]. However, the long-term results of cusp extension with glutaraldehyde fixed autologous pericardium remain unknown [6].
Repair of bicuspid aortic valves may bear the risk of subsequent dilatation of the ascending aorta [4, 7]. Aggressive aortoplasty of the ascending may prevent a secondary dilatation of the ascending aorta and aortic root [4]. Judgement of whether aortoplasty will be sufficient in the long term is difficult. In 40 patients we relied on this technique [4]; however in the 14 patients reported in this series, the aortic wall was deemed to be too thin and was enlarged for repair.
The geometric peculiarity of a bicuspid aortic root complicates repair. We were able to achieve this with the described modification of the resuspension technique by a special trim of the prostheses, correct spacing of the commissures, and patch augmentation of the fused leaflet.
In summary, our results are encouraging and prove that by a geometric modification of the David procedure, bicuspid aortic valves can be effectively repaired. Adapting the shape of the prostheses to the asymmetric aortic root, augmenting the deficit in height of the fused leaflet, and generous plication of the nonfused leaflet increased the height of coaptation, which gave the reconstruction an additional margin of safety, which increases reliability. This technique is associated with low rates of valve-related complications.
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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;103:617-622.[Abstract]
- Moritz A, Risteski P, Dogan S, et al. Six stitches to create a neosinus in David-type aortic root resuspension J Thorac Cardiovasc Surg 2007;133:560-562.[Free Full Text]
- Doss M, Moidl R, Wood JP, Miskovic A, Martens S, Moritz A. Pericardial patch augmentation for reconstruction of incompetent bicuspid aortic valves Ann Thorac Surg 2005;80:304-307.[Abstract/Free Full Text]
- Doss M, Sirat S, Risteski P, Martens S, Moritz A. Pericardial patch augmentation for repair of incompetent bicuspid aortic valves at midterm Eur J Cardiothorac Surg 2008;33:881-884.[Abstract/Free Full Text]
- Casselman FP, Gillinov AM, Akhrass R, Kasirajan V, Blackstone EH, Cosgrove DM. Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet Eur J Cardiothorac Surg 1999;15:302-308.[Abstract/Free Full Text]
- Duran CM, Gometza B, Shahid M, Al-Halees Z. Treated bovine and autologous pericardium for aortic valve reconstruction Ann Thorac Surg 1998;66:166-169.[Abstract/Free Full Text]
- Alsoufi B, Borger MA, Armstrong S, Maganti M, David TE. Results of valve preservation and repair for bicuspid aortic valve insufficiency J Heart Valve Dis 2005;14:752-759.[Medline]
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Abstract
Introduction
