Eur J Cardiothorac Surg 2006;29:416-418
© 2006 Elsevier Science NL
Complete aortic root reimplantation facilitates preservation of the aortic valve
Matthias Karck
*
,
Hiroyuki Kamiya,
Christoph Bara,
Axel Haverich
Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
Received 2 August 2005;
received in revised form 2 October 2005;
accepted 13 October 2005.
* Corresponding author. Tel.: +49 511 532 6583; fax: +49 511 532 5404. (Email: karck.matthias{at}mh-hannover.de).
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Abstract
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The optimal technique for preservation of a retainable aortic valve is yet to be defined. We present a new facilitated procedure allowing for reimplantation of the complete aortic root in selected patients with acute type A aortic dissection or ascending aortic aneurysm.
Key Words: Aortic valve reimplantation • Aortic dissection • Aortic root reconstruction
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1. Introduction
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Aortic valve reimplantation, according to David and co-workers [1,2], requires reimplantation of both neo-coronary sinuses and the coronary ostia into a vascular prosthesis. This potentially time-consuming aspect limits its acceptance, particularly in patients with acute type A dissection [3,4]. We have therefore devised a new facilitated technique aiming at reimplantation of the complete aortic root into a vascular graft necessitating two horizontal suture lines only.
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2. Materials and methods
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2.1 Surgical technique
During cardioplegic cardiac arrest the proximal portion of the ascending aorta is transsected at the sinotubular junction. After mobilization of the aortic root including the space below the coronary ostia, 9–12 double armed unpledgetted sutures are placed from inside out in a horizontal plane directly underneath the aortic valve annulus as described by David and co-workers [1,2].
The arms of the two sutures below the left and the right coronary ostium are passed through the annulus with the needles guided out on both sides of the ostium.
Then, a slitlike incision at sites corresponding to the position of the coronary ostia is made in a vascular graft of appropriate size. The length of this incision corresponds to the distance between the base of the aortic root where the vascular graft will be anchored and the origin of the coronary ostia. The needles of the sutures underneath the coronary ostia are now stitched through the base of the graft perimeter at each side of the incision in the graft. After all other sutures are passed through the graft, it is tied down to the aortic annulus. Before doing so at the level of the coronary ostia, one arm of the respective suture is guided underneath the coronary ostium to the other side. This manoeuvre enables tying of this particular suture at one and the same side of the artery. The coronary ostia are now located within the incisions in the vascular graft (Fig. 1a).
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Fig. 1. (a) Intraoperative view of completed aortic root reimplantation. The arrow indicates the keyhole incision in the vascular graft housing the left coronary ostium. (b) Schematic presentation of this operation: 9–11 sutures anchor the vascular graft in the aortic root. Both coronary arteries are located in keyhole-like incisions of the vascular graft. A single circumferential suture unifies the dissected aortic root and the distal end of the vascular graft. (c) Postoperative MR-angiography in a patient (S.H.) at 31 months follow-up. The white arrows show the right and the left coronary ostia. There is no evidence of dilation of the coronary reimplantation sites.
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Another single suture line unifiying the layers of the dissected aortic root and the distal end of the vascular graft at the level of the sinotubular junction completes aortic root reimplantation (Fig. 1b). Downstream aortic pathology at the level of the aortic arch or beyond may be treated as required and according to the surgeons’ preferences.
2.2 Patients
Four patients (mean age: 70 years) were operated between December 2002 and March 2005 using aortic root reimplantation. Patient characteristics are given in Table 1
. Three patients were operated for acute type A aortic dissection and one patient for supracommissural ascending aortic aneurysm and moderate aortic valve insufficiency. Additional procedures included proximal aortic arch replacement in all three patients with acute aortic dissection type A.
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3. Results
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All patients survived the procedures and were extubated within 48 h postoperatively. Their further postoperative course was uneventful. At a mean follow-up of 23 months, all patients were alive and in NYHA functional class II or less. While all patients were followed by echocardiography, two patients underwent additional cardiac MRI at 31 and 27 months postoperatively (Fig. 1c). In two patients, the aortic valve was completely competent, while the other two patients presented with a mild aortic regurgitation at their last examination. The echocardiographic dimensions of the aortic root were found to be normal in all patients with no evidence of dilatation near the reimplantation sites of the coronary arteries (Table 1).
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4. Discussion
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The technical variant described here is based on the hypothesis that the dissected aortic root will not dilate once reimplanted completely into a vascular prosthesis. More than two years of follow-up of our two patients with acute type A aortic dissection by MRI and echocardiography indicate that this goal is likely to be accomplished. The fact that the coronary ostia are placed inside a keyhole-shaped tip of a slitlike incision in one end of the vascular prosthesis instead of being actively sutured into a circular window created in the graft did not cause secondary dilatation near that site so far. This observation is likely to be supported by the sutures reunifying the base of this incision below the coronary ostia.
This technique allows for reimplantation of the complete aortic root into a vascular graft, accomplished by two suture lines only: one through the plane below the aortic valve and another at the level of the sinotubular junction. It may be used in patients with acute type A aortic dissection, who do not present with an intimal tear reaching proximal the level of the aortic valve commissures. In addition, it can be considered in patients with supracommissural ascending aortic aneurysms and a nondilated sinotubular junction. Even though the average cross clamp time was still quite long at this early stage of experience, we believe that this technical variant may facilitate preservation of the aortic valve in patients with pathologies of the aortic root.
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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;103:617-621.[Abstract]
- Feindel CM, David TE. Aortic valve sparing operations: basic concepts. Int J Cardiol 2004;97(Suppl. 1):61-66.
- Kallenbach K, Oelze T, Salcher R, Hagl C, Karck M, Leyh RG, Haverich A. Evolving strategies for treatment of acute aortic dissection type A. Circulation 2004;110(11 Suppl. 1):II243-II249.
- Karck M, Kallenbach K, Hagl C, Rhein C, Leyh R, Haverich A. Aortic root surgery in Marfan syndrome: comparison of aortic valve-sparing reimplantation versus composite grafting. J Thorac Cardiovasc Surg 2004;127:391-398.[Abstract/Free Full Text]
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Abstract
1. Introduction
