Medicine
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Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement
Chapters
Summary 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.
Transcript
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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