Aortic valve-sparing surgery techniques

Editor's Notes

1. Even, post valve sparing procdr, there r unphysiologic movement of valve cusp, still gradien occurred were equal to normal cusp motion.. <<5mmHg
2. Both techniques are reported to provide excellent functional results, with a low pressure gradient and no or minimal aortic regurgitation
3. remodeling technique described by Yacoub and colleagues which replaces the sinuses separately, and reimplantation technique of David and Feindel which replaces the entire wall of the aortic root with a straight prosthetic tube
4. The opening in the graft should he at least twice as large as the diameter of the coronary artery hcause a thick pseudointima (up to 3 mm) develops along the anastomotic line Excessively large orifices in the graft may cause late aneurysm of the remnants of the aortic sinus tissue and too small orifices may result in late stenoses of the c:oronary artery ostia. The upper part of the Dac-ron graft is then sutiired to the distal aswntling aorta or to a graft that may have been used to replace the transverse aortic. arch.
5. The ascending aorta is transected 1 cm above the commissures of the aortic valve (A). The aortic leaflets are then carefully inspected. One needs not to measure the length of the free margin and the length of the base of each leaflet to determine if it they are overstretched or not. This assessment can be performed simply by holding the arterial walls immediately above the commissures of a leaflet at an appropriate distance from each other and observing the leaflet. If it does not prolapse, it is an indication that its free margin is shorter than its base. If all three leaflets are fairly normal or only minimally stretched, remodeling of the aortic root with preservation of the aortic valve is feasible.The aortic root is circumferentially dissected down to the level of the aortoventricular junction. The aortic root has to be freed from the pulmonary artery, the right ventricle, and the roof of the left atrium. Next, all three aortic sinuses are excised, leaving only 4 to 6 mm of arterial wall attached to the aortic annulus and around each coronary artery orifice. Both coronary arteries should be mobilized for a length of 1.5 to 2 cm to facilitate reimplantation later on (B)
6. 5. The length of the free margin and the height of each leaflet are measured and averaged. The diameter of the aortic annulus should not exceed the length of the free margin of the leaflets or twice the height of the leaflets. Because these patients have annuloaortic ectasia, a reduction in the diameter of the aortic annulus is often necessary. It is important to remember that the dilatation of the aortic annulus occurs only along its fibrous components. Thus, reduction of the aortic annulus is performed along its fibrous portion. This is accomplished by an aortic annuloplasty. Multiple horizontal mattress sutures of 4-0 or 3-0 multifilament polyester are passed from the inside to the outside of the fibrous portion of the left ventricular outflow tract immediately below the lowest level of the aortic annulus through a single horizontal plane (A, B). These sutures are then passed through a strip of Dacron fabric to reduce the diameter of the aortic annulus, especially underneath the commissures of the noncoronary leaflet (C). All sutures are tied outside of the aortic root (D). The aortic annuloplasty is completed.
7. Bsa <2 m2.. 21 sizer….. 23 sizer
8. Pitfall.. Obstruc anastm of buttoned coronary.. Lead to LV failure
9. Initially only patients with normal aortic valve leaflets had these operations, but more recently we utilized them in patients with prolapse of a single leaflet and in those with a bicuspid aortic valve The AV leaflets are often normal for age, and reduction of the sinotubular junction with an appropriate tubular Dacron graft is all that is needed to restore valve competence. The diameter of this graft should not exceed that of the average length of the free margins of the AV leaflets [3]. However, if the average length of the free margins of the leaflets is less than 24 mm, it is preferable to use a larger graft and reduce its diameter in the area where it is anastomosed to the aortic root, because grafts with small diameters in the ascending aorta can increase left ventricular afterload and cause heart failure.
10. Key featues of failed valve sparring op.. Is unreg cusp prolaps
11. Several authors suggested that use of the Yacoub technique in Marfan syndrome might be associated with a higher risk of reoperation for AI David et al prefer the David to the Yacoub technique when the aortic annulus is >27 mm in men and >25 mm in women. They believe that the Yacoub technique provides excellent results in older patients with a normal aortic annulus. Hanke et al suggested an annulus diameter of 28–30 mm as a cut-off below which the Yacoub technique and above which the David technique may give a superior outcome.
12. Less fredom fr AI, but doesn’t mean higer freddom fr reoperation Repairing a bad cusp
13. Few paper about valve spar failure, ao valve stree, etc.. N the important need of sinus…. They try to make sinus illustrates the principles of the different surgical procedures. In all aortic roots, the 3 sinuses of Valsalva were resected, leaving a rim of sinus tissue of 2 mm to the fibrous ring of the cusps. For the remodeling technique, the Dacron tube was trimmed in a 3-tongue fashion for replacement of the sinuses (Figure 1, a). The graft was sewn on the remaining aortic root by using a continuous 4-0 Prolene suture (Ethicon, Norderstedt, Germany). The remodeling technique was modified by sewing the 3 tongues separately into the resected sinuses, enabling more precise matching and easier surgical handling of the sinus reconstruction (Figure 1, b). Finally, the remaining Dacron tube was sewn onto the reconstructed root at the height of the sinotubular junction. The sinus prosthesis was self-manufactured. A Dacron tube was trimmed by inserting sinus of Valsalva–shaped pieces of the same tube into the graft for creation of the sinuses. The 3 neosinuses were inserted by turning the prosthetic material at a 90° angle to use the distensibility of the Dacron material in circumferential direction (Figure 1, c). The aortic valve was implanted into this prosthesis by using interrupted, U-shaped 4-0 Prolene sutures at the annulus in a planar fashion and a continuous 4-0 Prolene suture for attachment of the valve from inside the prosthesis. The sinus prosthesis was further modified by inserting 3 square pieces of the same graft into the tube after turning them by 90°, with no rim of the Dacron tube left at the base of the sinus (Figure 1, d). This prosthesis enables the surgeon to adapt the height of the graft to the varying heights of the commissures of the pig aortic root. The aortic valve was then inserted into the prosthesis, as described for the sinus prosthesis. For the original reimplantation technique, the aortic valve was implanted into an untrimmed Dacron tube (Figure 1, e), as described above. For the modified reimplantation technique (Figure 1, f), a 6-mm-larger graft was downsized to the calculated diameter during the proximal anastomosis by using mattress Teflon felt-pledgeted sutures placed in a horizontal plane at the annulus. The valve was then implanted from inside the Dacron tube with 4-0 Prolene continuous sutures. At the sinotubular junction, another graft tailored to the calculated diameter was sutured to the larger proximal prosthesis.
14. KI.. Old, limited life expc, poor LV, unstab, anticoag, large annulus
15. Aortic root distensibility, expressed as diastolic-to-systolic change of area, decreased in all surgical procedures compared with that of the native aortic root (Figure 6). The cyclic changes of cross-sectional areas were significantly more pronounced for the remodeling and modified remodeling techniques and also for the sinus prosthesis at the sinotubular junction compared with the reimplantation and modified reimplantation techniques and the modified sinus prosthesis. At the commissural level, the reimplantation and the modified reimplantation techniques had the lowest values (6.0% ± 1.6% and 3.94% ± 1.2%, respectively). Distensibility was greater for the sinus and modified sinus prosthesis (9.2% ± 2.6% and 10.4% ± 4.3%, P < .02) and even more for the remodeling and modified remodeling techniques (17.2% ± 5.1% and 17.2% ± 6.4%, P < .01). At the sinus level, no differences were observed between the surgical procedures, and for area changes of less than 5% during the cardiac cycle, none of the techniques were distensible Differences in distensibility between the surgical techniques could be found at the annular level. Although the reimplantation techniques and sinus prosthesis were comparable with the native root, a significant increase of annular distensibility was noted for the remodeling (9.88% ± 5.4%, P = .026) and modified remodeling (8.71% ± 4.3%, P = .017) techniques, as well as for the modified sinus prosthesis (8.68% ± 2.2%, P = .009), compared with the native root (5.16% ± 1.82%).