HOW TO DO IT
Modified Aortic Root Replacement Technique in Destructive Ventricular-Aortic Discontinuity Alireza Alizadeh Ghavidel, MD, Hoda Javadikasgari, MD, Anita Sadeghpour, MD, and Ziae Totonchi, MD Heart Valve Disease Research Center; Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Science, Tehran, Iran
We describe a simple technique for aortic root replacement in destructive prosthetic aortic valve endocarditis wherein the fragile aortic annulus tissue is not suitable for suture placement. Therefore, we first reconstructed the intervalvular part with a nontreated pericardial patch and then implanted the aortic composite graft on the
aortic root through the roof of the left atrium and reconstructed the defect thus made with another pericardial patch. No complication was seen at 6-month follow up.
P
adjacent to the anatomic position of the left coronary leaflet, respectively. Suturing the superior part of the patch to the fragile aortic annulus remnant (between the noncoronary and left coronary leaflets) aroused great concern about the risk of intraoperative aortic root bleeding and subsequent dehiscence of the prosthesis, paravalvar leakage, and pseudoaneurysm. Therefore, the superior part of the patch was sewn to the remnant tissue of the left atrium. Then, the mitral valve was replaced by a prosthetic valve, preserving the posterior leaflet and its subvalvular apparatus. In spite of the lack of any fibrous tissue in the aortic annulus between the noncoronary and left coronary leaflets, we decided on a new technique to implant the posterolateral part of the composite graft. Therefore, the left atrial roof was linearly opened (superior to the attached place of the pericardial patch), and the composite graft was implanted on the aortic root (at the anatomic position of the aortic annulus) through the left atrial roof with everted Teflon felted 2-0 Prolene vertical mattress sutures (Fig 1). The other parts of the composite graft were also sutured to the remnant tissues of the aortic annulus. The roof of the left atrium was reconstructed with another nontreated autologous pericardial patch. As in conventional techniques, the left coronary ostium was implanted on the composite graft. The distal part of the tube graft was anatomized to the first part of the ascending aorta, and the right coronary artery ostium was implanted on the other side of the composite graft.
Technique After radical resection of all infected and necrotic tissues, the coronary ostia were dissected and became ready as a coronary button. First, we tried to reconstruct and reinforce the intervalvular tissue with a nontreated autologous pericardial patch. The inferior, medial, and lateral parts of the patch were sewn to the remnant tissues in the mitral annulus, right fibrous trigone, and aortic annulus
Accepted for publication June 7, 2013. Address correspondence to Dr Ghavidel, Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Vali-Asr Ave, Niyayesh Blvd, 199691-1151, Tehran, Iran; e-mail: aaghavidel@ yahoo.com.
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Clinical Experience We used this modified technique with an early excellent result in a 38-year-old man who had previously undergone aortic valve replacement. Initial transesophageal echocardiography (TEE) showed severe left ventricular enlargement (6.8 cm) with normal left ventricular ejection fraction (LVEF) (55% to 60%). Right ventricular size and function were normal. The mechanical prosthetic aortic valve (PAV) had severe paravalvular 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.06.066
FEATURE ARTICLES
rosthetic aortic valve endocarditis complicated by destruction of the aortic annulus is a potentially fatal complication of aortic valve replacement. The surgical treatment of this condition is challenging, with operative mortality rates ranging from 7.3% to 33.0% [1], whereas the surgical mortality rate of the third redo operation for recurrent prosthethic aortic valve endocarditis can be as high as 55.6% [2]. Minimizing the risk of recurrent endocarditis can be achieved only by means of a very radical surgical approach. Adequate debridement and also destruction of the fibrous tissue support within the aortic root reduce the amount of healthy tissue available for reconstruction by the usual surgical techniques. Therefore, direct suture repair and valve replacement often fail for this reason. This is a formidable situation called ventricular-aortic discontinuity, and very few reports have described such devastating infection [3]. We report a simple modified technique for aortic root replacement in a situation where the anterior leaflet of the mitral valve and intervalvular fibrous continuity were destroyed and the aortic annulus remnant was extremely fragile for the patch or composite graft to be sewn.
(Ann Thorac Surg 2014;97:347–9) Ó 2014 by The Society of Thoracic Surgeons
348
HOW TO DO IT GHAVIDEL ET AL MODIFIED AORTIC ROOT REPLACEMENT
Ann Thorac Surg 2014;97:347–9
Fig 1. Pericardial patch and everted Teflon felted vertical mattress sutures.
FEATURE ARTICLES
leakage from both sides of the sewing ring (mostly on the postromedial side) secondary to large dehiscence and upward displacement. A large (2.5 cm 2.7 cm) nonpulsatile echo-free space was detected around the PAV suggestive of a ring abscess. Multiple mobile particles around the sewing ring and valve leaflets were suggestive of vegetations. Color flow Doppler demonstrated a tiny (2mm) defect in the noncoronary sinus (near its junction to the left coronary sinus), which suggested perforation of the Valsalva sinus to the left atrium. The patient also had severe functional mitral regurgitation. Because of the extent of the disease and also the severe involvement of the proximal part of the aorta, the team of surgeons decided to replace the aortic root with the proposed technique. We observed no intraoperative bleeding need for further suturing or revision of the aortic root. The initial TEE in the operating room demonstrated an LVEF of 35% to 40% and acceptable results of a hemodynamic study for the mechanical prosthetic mitral valve and replaced aortic valve and aortic root (peak gradient ¼ 28 mm Hg). The follow-up TEE during his uneventful postoperative period and 6 months after operation showed normal left ventricular size and LVEF (40%). Both valves had normal leaflet motion without any paravalvular leakage or mass.
Comment Several innovative techniques have been used to repair aortic root defects. Danielson and colleagues [4] implanted the PAV in the ascending aorta and used reversed saphenous vein bypass grafting to reconnect the
right and left coronary artery systems to the aortic artery. Although this technique promotes abscess healing, the systemic pressure might expand the subannular aneurysm. Brown and colleagues [5] bypassed the aortic root in a dog by inserting a valved conduit between the left ventricular apex and the descending thoracic aorta. A reversed saphenous vein bypass graft connected the descending thoracic aorta and the left anterior descending coronary artery. Although this technique obviates inserting the new prosthetic valve in the infected area, secondary closure of friable necrotic tissue against systemic pressure and adding length and complexity to the operation would be its disadvantages [5]. Implanting either a synthetic [6] or a biological tube graft [7] to the base of the heart and inserting the coronary ostia to the sides of the graft is another technique. Later results have shown that if the aortic annulus is involved, the defect created by the resection should be patched by either autologous or xenogenic pericardium before prosthetic valve implantation [8]. The difficulty in situations like that reported here was the extent of tissue destruction in the aortic annulus (especially the anatomic position of the noncoronary and left coronary leaflets junction) and the intervalvular fibrous body, which resulted in ventricular-aortic discontinuity. Reconstructing the intervalvular fibrous tissue by a pericardial patch has previously been demonstrated [9], but this technique was not applicable in our case because the posteromedial part of the aortic annulus lacked any safe and firm fibrous tissue to attach either the superior part of pericardial patch or the posterolateral part of composite graft. Therefore, we proposed a new
modified technique to reconstruct the intervalvular defect and implant the composite graft on the remnant aortic annulus by the help of the left atrial roof.
HOW TO DO IT GHAVIDEL ET AL MODIFIED AORTIC ROOT REPLACEMENT
5.
References 1. Wang A, Athan E, Pappas PA, et al. Contemporary clinical profile and outcome of prosthetic valve endocarditis. JAMA 2007;297:1354–61. 2. Romano G, Carozza A, Della Corte A, et al. Native versus primary prosthetic valve endocarditis: Comparison of clinical features and long-term outcome in 353 patients. J Heart Valve Dis 2004;13:200–8. discussion 208–9. 3. Okada K, Tanaka H, Takahashi H, et al. Aortic root replacement for destructive aortic valve endocarditis with left ventricular-aortic discontinuity. Ann Thorac Surg 2008;85: 940–5. 4. Danielson GK, Titus JL, DuShane JW. Successful treatment of aortic valve endocarditis and aortic root abscesses by insertion
6. 7. 8. 9.
349
of prosthetic valve in ascending aorta and placement of bypass grafts to coronary arteries. J Thorac Cardiovasc Surg 1974;67:443–9. Brown JW, Salles CA, Kirsh MM. Extraanatomical bypass of the aortic root: An experimental technique. Ann Thorac Surg 1977;24:433–8. Krasopoulos G, David TE, Armstrong S. Custom-tailored valved conduit for complex aortic root disease. J Thorac Cardiovasc Surg 2008;135:3–7. David TE, Regesta T, Gavra G, Armstrong S, Maganti MD. Surgical treatment of paravalvular abscess: Long-term results. Eur J Cardiothorac Surg 2007;31:43–8. d’Udekem Y, David TE, Feindel CM, Armstrong S, Sun Z. Long-term results of operation for paravalvular abscess. Ann Thorac Surg 1996;62:48–53. De Oliveira NC, David TE, Armstrong S, Ivanov J. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body: An analysis of clinical outcomes. J Thorac Cardiovasc Surg 2005;129:286–90.
FEATURE ARTICLES
Ann Thorac Surg 2014;97:347–9
Modified Aortic Root Replacement Technique in Destructive Ventricular-Aortic Discontinuity Alireza Alizadeh Ghavidel, MD, Hoda Javadikasgari, MD, Anita Sadeghpour, MD, and Ziae Totonchi, MD Heart Valve Disease Research Center; Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Science, Tehran, Iran
We describe a simple technique for aortic root replacement in destructive prosthetic aortic valve endocarditis wherein the fragile aortic annulus tissue is not suitable for suture placement. Therefore, we first reconstructed the intervalvular part with a nontreated pericardial patch and then implanted the aortic composite graft on the
aortic root through the roof of the left atrium and reconstructed the defect thus made with another pericardial patch. No complication was seen at 6-month follow up.
P
adjacent to the anatomic position of the left coronary leaflet, respectively. Suturing the superior part of the patch to the fragile aortic annulus remnant (between the noncoronary and left coronary leaflets) aroused great concern about the risk of intraoperative aortic root bleeding and subsequent dehiscence of the prosthesis, paravalvar leakage, and pseudoaneurysm. Therefore, the superior part of the patch was sewn to the remnant tissue of the left atrium. Then, the mitral valve was replaced by a prosthetic valve, preserving the posterior leaflet and its subvalvular apparatus. In spite of the lack of any fibrous tissue in the aortic annulus between the noncoronary and left coronary leaflets, we decided on a new technique to implant the posterolateral part of the composite graft. Therefore, the left atrial roof was linearly opened (superior to the attached place of the pericardial patch), and the composite graft was implanted on the aortic root (at the anatomic position of the aortic annulus) through the left atrial roof with everted Teflon felted 2-0 Prolene vertical mattress sutures (Fig 1). The other parts of the composite graft were also sutured to the remnant tissues of the aortic annulus. The roof of the left atrium was reconstructed with another nontreated autologous pericardial patch. As in conventional techniques, the left coronary ostium was implanted on the composite graft. The distal part of the tube graft was anatomized to the first part of the ascending aorta, and the right coronary artery ostium was implanted on the other side of the composite graft.
Technique After radical resection of all infected and necrotic tissues, the coronary ostia were dissected and became ready as a coronary button. First, we tried to reconstruct and reinforce the intervalvular tissue with a nontreated autologous pericardial patch. The inferior, medial, and lateral parts of the patch were sewn to the remnant tissues in the mitral annulus, right fibrous trigone, and aortic annulus
Accepted for publication June 7, 2013. Address correspondence to Dr Ghavidel, Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Vali-Asr Ave, Niyayesh Blvd, 199691-1151, Tehran, Iran; e-mail: aaghavidel@ yahoo.com.
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Clinical Experience We used this modified technique with an early excellent result in a 38-year-old man who had previously undergone aortic valve replacement. Initial transesophageal echocardiography (TEE) showed severe left ventricular enlargement (6.8 cm) with normal left ventricular ejection fraction (LVEF) (55% to 60%). Right ventricular size and function were normal. The mechanical prosthetic aortic valve (PAV) had severe paravalvular 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.06.066
FEATURE ARTICLES
rosthetic aortic valve endocarditis complicated by destruction of the aortic annulus is a potentially fatal complication of aortic valve replacement. The surgical treatment of this condition is challenging, with operative mortality rates ranging from 7.3% to 33.0% [1], whereas the surgical mortality rate of the third redo operation for recurrent prosthethic aortic valve endocarditis can be as high as 55.6% [2]. Minimizing the risk of recurrent endocarditis can be achieved only by means of a very radical surgical approach. Adequate debridement and also destruction of the fibrous tissue support within the aortic root reduce the amount of healthy tissue available for reconstruction by the usual surgical techniques. Therefore, direct suture repair and valve replacement often fail for this reason. This is a formidable situation called ventricular-aortic discontinuity, and very few reports have described such devastating infection [3]. We report a simple modified technique for aortic root replacement in a situation where the anterior leaflet of the mitral valve and intervalvular fibrous continuity were destroyed and the aortic annulus remnant was extremely fragile for the patch or composite graft to be sewn.
(Ann Thorac Surg 2014;97:347–9) Ó 2014 by The Society of Thoracic Surgeons
348
HOW TO DO IT GHAVIDEL ET AL MODIFIED AORTIC ROOT REPLACEMENT
Ann Thorac Surg 2014;97:347–9
Fig 1. Pericardial patch and everted Teflon felted vertical mattress sutures.
FEATURE ARTICLES
leakage from both sides of the sewing ring (mostly on the postromedial side) secondary to large dehiscence and upward displacement. A large (2.5 cm 2.7 cm) nonpulsatile echo-free space was detected around the PAV suggestive of a ring abscess. Multiple mobile particles around the sewing ring and valve leaflets were suggestive of vegetations. Color flow Doppler demonstrated a tiny (2mm) defect in the noncoronary sinus (near its junction to the left coronary sinus), which suggested perforation of the Valsalva sinus to the left atrium. The patient also had severe functional mitral regurgitation. Because of the extent of the disease and also the severe involvement of the proximal part of the aorta, the team of surgeons decided to replace the aortic root with the proposed technique. We observed no intraoperative bleeding need for further suturing or revision of the aortic root. The initial TEE in the operating room demonstrated an LVEF of 35% to 40% and acceptable results of a hemodynamic study for the mechanical prosthetic mitral valve and replaced aortic valve and aortic root (peak gradient ¼ 28 mm Hg). The follow-up TEE during his uneventful postoperative period and 6 months after operation showed normal left ventricular size and LVEF (40%). Both valves had normal leaflet motion without any paravalvular leakage or mass.
Comment Several innovative techniques have been used to repair aortic root defects. Danielson and colleagues [4] implanted the PAV in the ascending aorta and used reversed saphenous vein bypass grafting to reconnect the
right and left coronary artery systems to the aortic artery. Although this technique promotes abscess healing, the systemic pressure might expand the subannular aneurysm. Brown and colleagues [5] bypassed the aortic root in a dog by inserting a valved conduit between the left ventricular apex and the descending thoracic aorta. A reversed saphenous vein bypass graft connected the descending thoracic aorta and the left anterior descending coronary artery. Although this technique obviates inserting the new prosthetic valve in the infected area, secondary closure of friable necrotic tissue against systemic pressure and adding length and complexity to the operation would be its disadvantages [5]. Implanting either a synthetic [6] or a biological tube graft [7] to the base of the heart and inserting the coronary ostia to the sides of the graft is another technique. Later results have shown that if the aortic annulus is involved, the defect created by the resection should be patched by either autologous or xenogenic pericardium before prosthetic valve implantation [8]. The difficulty in situations like that reported here was the extent of tissue destruction in the aortic annulus (especially the anatomic position of the noncoronary and left coronary leaflets junction) and the intervalvular fibrous body, which resulted in ventricular-aortic discontinuity. Reconstructing the intervalvular fibrous tissue by a pericardial patch has previously been demonstrated [9], but this technique was not applicable in our case because the posteromedial part of the aortic annulus lacked any safe and firm fibrous tissue to attach either the superior part of pericardial patch or the posterolateral part of composite graft. Therefore, we proposed a new
modified technique to reconstruct the intervalvular defect and implant the composite graft on the remnant aortic annulus by the help of the left atrial roof.
HOW TO DO IT GHAVIDEL ET AL MODIFIED AORTIC ROOT REPLACEMENT
5.
References 1. Wang A, Athan E, Pappas PA, et al. Contemporary clinical profile and outcome of prosthetic valve endocarditis. JAMA 2007;297:1354–61. 2. Romano G, Carozza A, Della Corte A, et al. Native versus primary prosthetic valve endocarditis: Comparison of clinical features and long-term outcome in 353 patients. J Heart Valve Dis 2004;13:200–8. discussion 208–9. 3. Okada K, Tanaka H, Takahashi H, et al. Aortic root replacement for destructive aortic valve endocarditis with left ventricular-aortic discontinuity. Ann Thorac Surg 2008;85: 940–5. 4. Danielson GK, Titus JL, DuShane JW. Successful treatment of aortic valve endocarditis and aortic root abscesses by insertion
6. 7. 8. 9.
349
of prosthetic valve in ascending aorta and placement of bypass grafts to coronary arteries. J Thorac Cardiovasc Surg 1974;67:443–9. Brown JW, Salles CA, Kirsh MM. Extraanatomical bypass of the aortic root: An experimental technique. Ann Thorac Surg 1977;24:433–8. Krasopoulos G, David TE, Armstrong S. Custom-tailored valved conduit for complex aortic root disease. J Thorac Cardiovasc Surg 2008;135:3–7. David TE, Regesta T, Gavra G, Armstrong S, Maganti MD. Surgical treatment of paravalvular abscess: Long-term results. Eur J Cardiothorac Surg 2007;31:43–8. d’Udekem Y, David TE, Feindel CM, Armstrong S, Sun Z. Long-term results of operation for paravalvular abscess. Ann Thorac Surg 1996;62:48–53. De Oliveira NC, David TE, Armstrong S, Ivanov J. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body: An analysis of clinical outcomes. J Thorac Cardiovasc Surg 2005;129:286–90.
FEATURE ARTICLES
Ann Thorac Surg 2014;97:347–9
