Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement
December 11th, 2017
Valve-sparing aortic root replacement has the advantage of preserving the patient's own aortic valve. The complexity of the reported techniques to date restricts their use to a limited number of cardiac surgeons. This protocol describes step-by-step a standardized technique reproducible by a greater number of cardiac surgeons.
The overall goal of this protocol is to describe in detail a Standardized and Reproducible Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement with particular emphasis on the management of the first row of the proximal suture. This method can help answer key questions regarding aortic valve preservation during aortic route replacement. The main advantage of this technique is that it uses a single graft with a pre-shaped sinus portion that helps standardization of the procedure.
Begin this procedure with patient selection as detailed in the text protocol. Prepare the surgery suite and the patient for surgery as previously described. Access the heart through a median sternotomy as referenced in the text protocol.
Then, prepare the aortic route for replacement by first grabbing the ascending aorta at the sinotubular junction with Carpentier dissection forceps. Then, make a horizontal opening with the 11 blade knife. Complete the aortotomy circumferentially and horizontally with Metzenbaum scissors.
After having transected the aorta, verify the absence of calcifications of the cusps and/or thickening and retraction of their free margin. Check the coronary ostia. Dissect the outer aspect of the noncoronary sinus down to the roof of the left atrium, free from the surrounding tissue.
Next, detach the right coronary ostium from the aortic wall with a generous circular patch, leaving five millimeters of the aortic wall remnant attached to the insertion of the cusps. Free the commissure between the noncoronary and right coronary sinus from the surrounding tissue. Dissect the outer aspect of the aortic wall remnant of the right coronary sinus free from the outflow tract of the right ventricle.
Then, free the outer aspect of the commissure between the noncoronary and left coronary sinus down to the roof of the left atrium. Excise the aortic wall of the noncoronary sinus leaving five millimeters of the aortic wall remnant attached to the insertion of the cusp. Separate the outer aspect of the commissure between the right and left coronary sinus from the surrounding tissue.
Take care not to injure the pulmonary artery. Then, detach the left coronary ostium from the aortic wall with the generous circular patch, leaving five millimeters of the aortic wall remnant attached to the insertion of the cusp. Mobilize the left main coronary artery over its first 10 millimeters.
Dissect the outer aspect of the aortic wall remnant of the left coronary sinus free from the roof of the left atrium. Start the proximal implantation of the prosthesis as described in the text protocol. The single most difficult step of this procedure is the placement of the first row of the sutures by taking care not to injure the membranous septum and the anterior leaflet of the mitral valve.
Place the fourth suture next to the third one in the direction of the commissure between the noncoronary and right coronary sinus. Avoid the base of the commissural triangle between the noncoronary and right coronary sinus, so as to not compromise the membranous septum. Start the first suture of the right coronary sinus two millimeters away from the base of the commissural triangle of the commissure between the noncoronary and right coronary sinus, thus skipping the membranous septum.
Put the following sutures of the right coronary sinus in the direction of the commissure between the left and right coronary sinus. Place the fourth suture of the right coronary sinus at the base of the commissural triangle of the commissure between the left and right coronary sinus. Now pass the mattress sutures inside out into the prosthesis.
Slide down the prosthesis, thus placing the valve inside it. Tie the mattress sutures gently and cut them. Start the second row of the proximal anastomosis as described in the text protocol.
Finish the second row of the proximal anastomosis by fixing the remnant of the aortic wall in parallel to the insertion of the cusp up to the commissure, between the noncoronary and right coronary sinus. Tie the two suture ends together at each commissure. Check the absence of aortic regurgitation by filling the prosthesis with saline and applying suction to the vent placed to the right pulmonary vein and the mitral valve into the left ventricle.
Reconnect the coronary ostia to the prosthesis by first creating a button hole in the left sinus of the prosthesis and placing the first stitch as detailed in the text protocol. Place the second stitch two millimeters to the right of the first one from inside out of the prosthesis and outside in of the left coronary ostium up to the mid height of the right ridge of the anastomosis. Put the suture end under light tension.
Continue the running suture on the left ridge of the anastomosis from outside in the prosthesis and from inside out of the left coronary ostium to meet the other end. Tie the two ends together. After creating a button hole on the right sinus of the prosthesis and starting a suture as detailed in the text protocol, continue the suture to the mid height of the right ridge of the anastomosis and put the end under light tension.
Complete the anastomosis by running the left ridge of the anastomosis to meet the other end. Tie the two ends together. Start the distal anastomosis as described in the text.
Complete the distal anastomosis by running the suture on the left ridge to meet the other end. Tie the ends together. Tilt the operating table in the Trendelenburg position.
Let the pump flow reduce to 50%of the full flow and slowly remove the aortic cross clamp under gentle aspiration of the left ventricular vent. After the procedure, resume the full flow of the cardiopulmonary bypass and check the operative field for undue surgical bleeding. Rewarm and separate the patient from the cardiopulmonary bypass.
Finally, perform a post-operative patient care as referenced in the text protocol. The Kaplan Meier survival curve reveals that there were a total of three deaths in this series during the follow-up period. Thus, the five-year survival rate in this series was 97.5%and the 10-year survival rate was 92.5%Two of the four patients with recurrent moderate aortic regurgitation, underwent re-operation because of the progredient left ventricle dilatation.
As a result, the freedom of re-operation for aortic valve replacement was 95.2%at five years and 93%at 10 years. For patients developed moderate aortic regurgitation during the follow up period. Therefore, their freedom from moderate aortic regurgitation was 91.6%at five years and 90%at 10 years.
Once mastered, this technique can be done in 150 minutes if it is performed properly. While attempting this procedure, it is important to remember to entirely free the aortic route from the surrounding tissue. After watching this video, you should have a good understanding of how to avoid injury to the membranous septum during the procedure.
Following this protocol, other surgical procedures on the aortic route can be performed to address different route pathologies. After its development, this technique opened the era of the preservation of the normal aortic valve during aortic route surgery. Don't forget that operating on the aortic route can be hazardous and gentle dissection of the tissue and placement of the sutures should always be taken while performing this procedure.
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Overview
This protocol outlines a standardized technique for valve-sparing aortic root replacement, focusing on aortic valve preservation. It aims to make the procedure reproducible for a wider range of cardiac surgeons.
Key Study Components
Area of Science
- Cardiac Surgery
- Aortic Valve Preservation
- Cardiovascular Techniques
Background
- Valve-sparing aortic root replacement preserves the patient's own aortic valve.
- Current techniques are complex and limited to experienced surgeons.
- This protocol aims to simplify the procedure.
- Standardization can improve surgical outcomes and accessibility.
Purpose of Study
- To describe a reproducible technique for aortic valve re-implantation.
- To emphasize the management of the proximal suture during surgery.
- To enhance understanding of aortic valve preservation.
Methods Used
- Patient selection criteria are outlined.
- Surgery suite preparation is detailed.
- Accessing the heart through median sternotomy is described.
- Use of a single graft with a pre-shaped sinus portion is emphasized.
Main Results
- The technique allows for better standardization of the procedure.
- It addresses key questions regarding aortic valve preservation.
- Improved reproducibility for cardiac surgeons is achieved.
- Potential for wider application in clinical settings.
Conclusions
- This protocol provides a clear framework for valve-sparing aortic root replacement.
- Standardization can lead to improved surgical outcomes.
- Wider adoption of the technique may benefit more patients.
Frequently Asked Questions
Executive Industry Relevance
This protocol addresses the challenge of limited accessibility to complex valve-sparing aortic root replacement procedures by introducing a standardized technique that improves reproducibility across surgical teams. By simplifying critical steps such as proximal suture placement and prosthesis sizing, the method supports broader adoption in clinical settings while maintaining favorable mid-term outcomes. This advancement enhances pipeline relevance for cardiovascular device development and preclinical model validation by providing a reliable, scalable approach to aortic valve preservation.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Scientific Value: Enables interrogation of therapeutic hypotheses related to aortic valve function and hemodynamic stability in disease models.
- Operational Value: Provides a reproducible surgical model for evaluating valve-sparing interventions in preclinical studies.
Screening & Assay Development
- Scientific Value: Supports preparation of validated biological systems for assessing device-tissue interactions and hemodynamic performance.
- Operational Value: Facilitates assay standardization through consistent prosthesis implantation and suture techniques.
Translational & Preclinical Research
- Scientific Value: Offers a disease-relevant system for studying aortic root pathology and valve durability under physiological conditions.
- Operational Value: Enables translational continuity from discovery through preclinical validation with measurable endpoints such as regurgitation rates and survival.
Pipeline & Workflow Integration
The technique fits within the discovery-to-preclinical continuum by providing a standardized model for aortic valve preservation studies, supporting hypothesis testing and mechanistic de-risking in cardiovascular research.
- Discovery Biology: Supports pathway clarification and biological de-risking by enabling consistent aortic valve re-implantation in experimental models.
- Screening: Enhances assay readiness and reproducibility through standardized prosthesis sizing and suture placement protocols.
- Analytics: Generates quantitative outputs such as survival rates, freedom from reoperation, and regurgitation incidence for comparative condition analysis.
- Translational Research: Connects to preclinical continuity via disease-relevant aortic root models and biomarker-aligned outcomes like valve durability.
- Enterprise Reuse: Establishes a reusable surgical capability for multi-institutional preclinical studies and device evaluation platforms.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence in valve-sparing strategies by reducing procedural variability and mechanistic ambiguity.
- Operational Value: Improves standardization, reproducibility, and scalability of aortic valve replacement procedures across surgical sites.
- Strategic Value: Supports better go/no-go decisions in device development by lowering biological risk and enhancing outcome predictability.
- Portfolio Impact: Enables risk-adjusted prioritization of cardiovascular interventions based on reproducible surgical outcomes.
Implementation Considerations
- Requires expertise in cardiac surgery and aortic anatomy for proper tissue dissection and suture technique.
- Depends on access to specialized instrumentation including Carpentier forceps, Metzenbaum scissors, and pre-shaped polyester prostheses.
- Necessitates cross-team standardization of suture protocols and prosthesis handling to ensure consistency.
- Involves adaptation considerations for varying patient anatomies, particularly aortic root dimensions and commissural height.
- Includes practical limitations such as the need for meticulous dissection to avoid injury to the membranous septum and anterior mitral leaflet.
Biopharma FAQs
Chapters in this video
0:05
Title
0:59
Surgery: Prepare the Aortic Root for Replacement
5:02
Surgery: Start the Proximal Implantation of the Prosthesis
8:28
Surgery: Reconnect the Coronary Ostia to the Prosthesis
10:45
Surgery: Perform the Distal Anastomosis
11:49
Results: Kaplan-Meier Curves at 10 Years
12:55
Conclusion
