How to Do It
Prosthesis-preserving aortic root repair after aortic valve replacement
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(6) 744–746 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314548434 aan.sagepub.com
Masaki Hamamoto, Taira Kobayashi and Hiroshi Kodama
Abstract We describe a new technique of prosthesis-preserving aortic root replacement for patients who have previously undergone aortic valve replacement. With preservation of the mechanical prosthesis, we implant a Gelweave Valsalva graft using double suture lines. The first suture line is made between the sewing cuff of the mechanical valve and the graft, with mattress sutures of 2/0 braided polyester with pledgets. After the first sutures are tied, the second suture line is created between the graft collar and the aortic root remnant with continuous 4/0 polypropylene sutures.
Keywords Anastomosis, surgical, aorta, aortic valve, blood vessel prosthesis implantation, sinus of Valsalva, vascular surgical procedures
Introduction Patients with a bicuspid aortic valve exhibit an inherent aortopathy, and the aortic root and ascending aorta might progressively dilate, even after aortic valve replacement.1,2 In the presence of a normally functioning prosthetic aortic valve, completion of aortic root replacement is technically challenging. Herein, we describe how to implant a vascular graft to the aortic root with a previously implanted mechanical prosthesis.
Technique Through a median resternotomy, cardiopulmonary bypass is established with cannulation of the axillary artery and the right atrium. The dilated aortic root is dissected near the coronary orifices. After cardioplegic arrest, the aorta is transected and the mechanical prosthesis (standard Carbomedics valve) is carefully inspected. The prosthetic valve can be preserved if it has no dysfunction, i.e., no leaflet immobilization by pannus or thrombus formation, or paravalvular leakage. The coronary buttons are created and the aortic wall is excised with a 1.5-cm rim around the prosthesis. A Gelweave Valsalva graft (Vascutek, Terumo, Ann Arbor, MI, USA) is selected according to the annular diameter of the prosthesis. Several 2/0 braided polyesters with pledgets are passed through the sewing cuff of
the prosthetic valve, and then to the upper level of the collar portion of the Valsalva graft as the first suture line (Figure 1A). The graft is seated down to the prosthetic valve and the sutures are tied securely. For the second suture line, the graft collar is sutured to the aortic wall remnant with 4/0 polypropylene running sutures (Figure 1B). Both coronary arteries, reinforced with Teflon felt, are reimplanted directly to the Valsalva graft with the button technique using 5/0 polypropylene running sutures. The distal anastomosis of the Valsalva graft is completed under moderate hypothermia with selective cerebral perfusion (Figure 1C).
Discussion For aortic root replacement in patients who have previously undergone aortic valve replacement, preservation of the prosthesis has the advantage of avoiding implantation of a composite graft in a fragile or damaged aortic annulus after resection of the Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan Corresponding author: Masaki Hamamoto, MD, PhD, Department of Cardiovascular Surgery, JA Hiroshima General Hospital, 1-3-3 Zigozen, Hatsukaichi, Hiroshima 738-8503, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at Monash University on November 17, 2015
Hamamoto et al.
745
Figure 1. (A) The first suture line is made between the sewing cuff of the preserved mechanical prosthesis and the upper level of the graft collar with mattress sutures of 2/0 braided polyester with pledgets. (B) The graft is seated down to the prosthesis and the mattress sutures are tied securely. For the second suture line, the graft collar is sutured to the aortic wall remnant with a 4/0 polypropylene running suture. (C) After reconstruction of both coronary arteries with the button technique and the distal anastomosis under moderate hypothermia with selective cerebral perfusion, the prosthesis-preserved aortic root replacement is completed. fSL: first suture line; LCA: left coronary artery; RCA: right coronary artery. sSL: second suture line.
prosthesis. Removal of the previous prosthesis consumes much more time, and subsequent implantation of the composite graft in the damaged annulus may cause paravalvular leakage or suture bleeding. On the other hand, there are some technical issues regarding how to implant a vascular graft with preservation of a mechanical prosthesis in the aortic position. Malekan and colleagues3 reported that the graft was secured to the sewing cuff of the previous prosthetic aortic valve together with the remnant aortic root wall, using a single 2/0 polypropylene running suture. These authors commented that the completion Bentall procedure may be a safer and shorter operation compared to complete aortic root reconstruction. In our technique, the graft is implanted into the aortic root with double suture lines for secure hemostasis. The first mattress sutures are placed directly at the prosthetic sewing cuff. The placement of stitches to the cuff inside the aortic root is technically easy without any need for dissection around the aortic root. After the first sutures are tied down, the second running sutures between the graft collar and remnant aortic wall are placed to cover the first sutures for reinforcement and hemostasis. Suturing the 10-mm-wide collar to the adjacent aortic remnant is also uncomplicated with minimal dissection of the aortic root, which can prevent any damage to the neighboring cardiac
structures. While these double sutures may prolong the operative time, compared to the technique described by Malekan and colleagues,3 our procedure decreases the potential risk of bleeding from suture holes and minimizes the dissecting area, thus making it easy to place some additional stitches against suture bleeding, even with the heart beating. Regarding the type of preserved mechanical prosthesis applicable to this technique, a standard type of mechanical prosthesis which has an appropriate volume of the sewing cuff, is a good indication for this technique. In contrast, a supraannular type of prosthesis may not be applicable because this type of mechanical valve has a small and floppy sewing cuff which makes the first sutures difficult to place. While this technique may not be suitable for all patients requiring a completion Bentall procedure, those reoperative cases with an intact standard-type mechanical prosthesis may benefit from this technique. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
Downloaded from aan.sagepub.com at Monash University on November 17, 2015
746
Asian Cardiovascular & Thoracic Annals 23(6)
References 1. McKellar SH, Michelena HI, Li Z, Schaff HV and Sundt TM 3rd. Long-term risk of aortic events following aortic valve replacement in patients with bicuspid aortic valves. Am J Cardiol 2010; 106: 1626–1633. 2. Borger MA, Preston M, Ivanov J, et al. Should the ascending aorta be replaced more frequently in patients with
bicuspid aortic valve disease? J Thorac Cardiovasc Surg 2004; 128: 677–683. 3. Malekan R, Spielvogel D, Saunders PC, Lansman SL and Griepp RB. The completion Bentall procedure. Ann Thorac Surg 2011; 92: 362–363.
Downloaded from aan.sagepub.com at Monash University on November 17, 2015
Prosthesis-preserving aortic root repair after aortic valve replacement
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(6) 744–746 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314548434 aan.sagepub.com
Masaki Hamamoto, Taira Kobayashi and Hiroshi Kodama
Abstract We describe a new technique of prosthesis-preserving aortic root replacement for patients who have previously undergone aortic valve replacement. With preservation of the mechanical prosthesis, we implant a Gelweave Valsalva graft using double suture lines. The first suture line is made between the sewing cuff of the mechanical valve and the graft, with mattress sutures of 2/0 braided polyester with pledgets. After the first sutures are tied, the second suture line is created between the graft collar and the aortic root remnant with continuous 4/0 polypropylene sutures.
Keywords Anastomosis, surgical, aorta, aortic valve, blood vessel prosthesis implantation, sinus of Valsalva, vascular surgical procedures
Introduction Patients with a bicuspid aortic valve exhibit an inherent aortopathy, and the aortic root and ascending aorta might progressively dilate, even after aortic valve replacement.1,2 In the presence of a normally functioning prosthetic aortic valve, completion of aortic root replacement is technically challenging. Herein, we describe how to implant a vascular graft to the aortic root with a previously implanted mechanical prosthesis.
Technique Through a median resternotomy, cardiopulmonary bypass is established with cannulation of the axillary artery and the right atrium. The dilated aortic root is dissected near the coronary orifices. After cardioplegic arrest, the aorta is transected and the mechanical prosthesis (standard Carbomedics valve) is carefully inspected. The prosthetic valve can be preserved if it has no dysfunction, i.e., no leaflet immobilization by pannus or thrombus formation, or paravalvular leakage. The coronary buttons are created and the aortic wall is excised with a 1.5-cm rim around the prosthesis. A Gelweave Valsalva graft (Vascutek, Terumo, Ann Arbor, MI, USA) is selected according to the annular diameter of the prosthesis. Several 2/0 braided polyesters with pledgets are passed through the sewing cuff of
the prosthetic valve, and then to the upper level of the collar portion of the Valsalva graft as the first suture line (Figure 1A). The graft is seated down to the prosthetic valve and the sutures are tied securely. For the second suture line, the graft collar is sutured to the aortic wall remnant with 4/0 polypropylene running sutures (Figure 1B). Both coronary arteries, reinforced with Teflon felt, are reimplanted directly to the Valsalva graft with the button technique using 5/0 polypropylene running sutures. The distal anastomosis of the Valsalva graft is completed under moderate hypothermia with selective cerebral perfusion (Figure 1C).
Discussion For aortic root replacement in patients who have previously undergone aortic valve replacement, preservation of the prosthesis has the advantage of avoiding implantation of a composite graft in a fragile or damaged aortic annulus after resection of the Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan Corresponding author: Masaki Hamamoto, MD, PhD, Department of Cardiovascular Surgery, JA Hiroshima General Hospital, 1-3-3 Zigozen, Hatsukaichi, Hiroshima 738-8503, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at Monash University on November 17, 2015
Hamamoto et al.
745
Figure 1. (A) The first suture line is made between the sewing cuff of the preserved mechanical prosthesis and the upper level of the graft collar with mattress sutures of 2/0 braided polyester with pledgets. (B) The graft is seated down to the prosthesis and the mattress sutures are tied securely. For the second suture line, the graft collar is sutured to the aortic wall remnant with a 4/0 polypropylene running suture. (C) After reconstruction of both coronary arteries with the button technique and the distal anastomosis under moderate hypothermia with selective cerebral perfusion, the prosthesis-preserved aortic root replacement is completed. fSL: first suture line; LCA: left coronary artery; RCA: right coronary artery. sSL: second suture line.
prosthesis. Removal of the previous prosthesis consumes much more time, and subsequent implantation of the composite graft in the damaged annulus may cause paravalvular leakage or suture bleeding. On the other hand, there are some technical issues regarding how to implant a vascular graft with preservation of a mechanical prosthesis in the aortic position. Malekan and colleagues3 reported that the graft was secured to the sewing cuff of the previous prosthetic aortic valve together with the remnant aortic root wall, using a single 2/0 polypropylene running suture. These authors commented that the completion Bentall procedure may be a safer and shorter operation compared to complete aortic root reconstruction. In our technique, the graft is implanted into the aortic root with double suture lines for secure hemostasis. The first mattress sutures are placed directly at the prosthetic sewing cuff. The placement of stitches to the cuff inside the aortic root is technically easy without any need for dissection around the aortic root. After the first sutures are tied down, the second running sutures between the graft collar and remnant aortic wall are placed to cover the first sutures for reinforcement and hemostasis. Suturing the 10-mm-wide collar to the adjacent aortic remnant is also uncomplicated with minimal dissection of the aortic root, which can prevent any damage to the neighboring cardiac
structures. While these double sutures may prolong the operative time, compared to the technique described by Malekan and colleagues,3 our procedure decreases the potential risk of bleeding from suture holes and minimizes the dissecting area, thus making it easy to place some additional stitches against suture bleeding, even with the heart beating. Regarding the type of preserved mechanical prosthesis applicable to this technique, a standard type of mechanical prosthesis which has an appropriate volume of the sewing cuff, is a good indication for this technique. In contrast, a supraannular type of prosthesis may not be applicable because this type of mechanical valve has a small and floppy sewing cuff which makes the first sutures difficult to place. While this technique may not be suitable for all patients requiring a completion Bentall procedure, those reoperative cases with an intact standard-type mechanical prosthesis may benefit from this technique. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement None declared.
Downloaded from aan.sagepub.com at Monash University on November 17, 2015
746
Asian Cardiovascular & Thoracic Annals 23(6)
References 1. McKellar SH, Michelena HI, Li Z, Schaff HV and Sundt TM 3rd. Long-term risk of aortic events following aortic valve replacement in patients with bicuspid aortic valves. Am J Cardiol 2010; 106: 1626–1633. 2. Borger MA, Preston M, Ivanov J, et al. Should the ascending aorta be replaced more frequently in patients with
bicuspid aortic valve disease? J Thorac Cardiovasc Surg 2004; 128: 677–683. 3. Malekan R, Spielvogel D, Saunders PC, Lansman SL and Griepp RB. The completion Bentall procedure. Ann Thorac Surg 2011; 92: 362–363.
Downloaded from aan.sagepub.com at Monash University on November 17, 2015
