Aortic valve-sparing operations in aortic root

aneurysms: remodeling or reimplantation?

Interactive CardioVascular and Thoracic Surgery 13 (2011) 189-197

J Thorac Cardiovasc Surg 2008;116:990-996

Dicky A.Wartono,MDAortic Endovascular Surgery

2013

• Conventional treatment of patients with aortic root pathology—using a composite tube graft• lifelong anticoagulation, • the risk of thromboembolism and bleeding, • the psychologic drawback of heart valve noise,• the unknown long-term effects of cerebral

microemboli, and• the continuous burden to the left ventricle owing

to increasing aortic outflow resistance.

valve-preserving techniques :•remodeling technique (by Yacoub and colleagues)•reimplantation technique (David and Feindel)

Dacron graft is anchored to the aortoventricular junction. The native

aortic valve is then resuspended within the vascular graft.

Dacron graft is tailored to conform the shape of the 3 aortic sinuses and then anastomosed to the aortic root.

• whether the reimplantation (David) technique or the remodeling (Yacoub) technique provides the optimum event free survival

• 14 papers provided the best evidence • total of 1338 patients (Yacoub technique in

606 and David technique in 732) • 13 centres were included

Valve sparing aortic replacement – root remodelingOperative Techniques in Thoracic and Cardiovascular Surgery 2005;10(4):246–258

The diseased aortic sinuses are excised down to the aortic annulus, which is always healthy and can hold sutures securely even in patients with acute dissection.

choosing an appropriately sized Dacron tube, passing horizontal mattress sutures just above the top of each commissure and stretching the three commissures in a vertical direction while observing the position of the cusps. 30-mm tube is required in large adults and a 20-mm tube in adolescents and small individuals

choosing graft size and take a graft of approximately 1 to 2 mm smaller than the diameter of the aorto-ventricular junction.

Three longitudinal cuts are made in one of the ends of the graft. The length of these longitudinal cuts should be approximately three fourths of the diameter of the graft. The ends are rounded (B)

suture are passed from the inside to the outside of the graft immediately ahovr the end of the longitudinal cuts, and then from the inside to the outside of the rtminants of the aortic.

The Dacron graft is then sutured to the remnants of the aortic sinuses along the aortic annulus. It is safer to start at the commissural level and to sew toward the central portion of the sinus to prevent maldistrihution of the tailored graft along the aortic. annulus. The graft should lie inside the remnants of the aortic sinuses.

aortic valve is tested for incompetence

If the. leaflets do not touch each other in the center, the graft may be too large; this can he corrected by sewing the diameter of the sinotubular junction.

If the leaflets coapt excessively, thev may prolapse under pressure.

the best method is by Doppler echocardiography after discontinuation of cardiopulmonary bypass.

The right and left coronary arteries are then reimplanted into their respective sinuses by making an opening in the graft and suturing the remnants of the sinus wall around each cornnary artery.

Valve-sparing aortic root replacement: the inclusion (David) technique Operative Techniques in Thoracic and Cardiovascular Surgery 2005;10(4):246–258

For the correct sizing of the appropriate Dacron graft, commissures must be pulled up to create a virtual cylinder with cusp coaptation of 30–50%.

Horizontal mattress sutures without pledges are placed in one lane underneath the sinuses for later fixation of the graft to the aortic root.

When knots of the horizontal mattress are

gently tied, the graft must be pushed down and held

in position by the assistant.A pivotal step of the

reimplantation procedure is the posi- tioning of the commissures high enough into the Dacron tube by pulling on the stay sutures, reshaping a correct geometry of the valve.

Valve implantation: slightly pulling on both the commissure and the vascular graft before stitching the sutures through the graft. the graft should extend roughly by half of its maximum length at this segment. Insertion of saline allows a first judgment of leakproofness of the valve.

After completion of the reimplantation, the valve must appear in means of the geometry like a ‘Mercedes star’, but indi- vidual differences in length of cusps are possible.

Completion of the procedure: Coronary ostia are reim- planted into the Dacron prosthesis by use of 5-0 monofilament run- ning suture. The prosthesio-prosthesio anastomosis was sewn in a routine fashion with 3-0 running monofilament suture. Weaning from extracorporeal circulation and deairing is performed, followed by control for bleeding. A graft inclusion should only include the distal portion of the graft.

The reimplan- tation of partially resected sinuses of valsalvae starts at the Nadir of the three coronary sinuses, each with double armed monofila- ment sutures going up to both commissures, where sutures were tied to each other. This suture line must be hemostatic! Stay sutures are tied and cut too.

Relationship between height of resuspension of the reimplanted valve and occurrence of postoperative aortic insufficiency.

Repair of prolapsing aortic leaflet with 6-0 Gore-Tex suture.

Intraoperative transesophageal echocardiographic criteria to appreciate quality of the result after valve repair

In 2003, Miller introduced a classification to the Tirone David's

• David-I is the original reimplantation procedure using a cylindrical tube graft, •David-II is the original Yacoub remodeling procedure, •David-III is the remodeling procedure with an external narrowing annuloplasty strip, •David-IV is reimplantation using a 4-mm larger graft size with plication of the graft circumferentially at the sinotubular junction (STJ) above the tops of the commissures, and •David-V is reimplantation using an even larger graft size, which is ‘necked down’ at both the bottom and the top ends to create graft pseudosinuses

Miller DC

. Valve-sparing aortic root replacement in patients with the Marfan syndrome. J Thorac Cardiovasc Surg 2003;125:773-778

Most important features of valve-preserving root replacement

• Early mortality ranged from – 0% to 6.9% for the Yacoub technique and – 0–6% for the David technique.

• In the largest available series reported by David et al. in 2010 – 1.6% in the Yacoub group and – 1.7% in the David group.

• acute type A dissection ,the overall early mortality was 17%

• CPB and aortic cross-clamp times were longer for the David technique

• freedom from moderate or severe AI within the follow-up period was more frequent for the David

• Both approaches have not been associated with thromboembolic complications, the risk of valve endocarditis

• Marfan syndrome, acute type A aortic dissection, and excessive annular dilatation may benefit from the David technique

• comparable results for both the Yacoub technique and the David technique in bicuspid aortic valve.

• the maximum systolic gradients measured in these reconstructed valves were essentially physiologic in all patients

Clinical bottom line• The results for both techniques were almost comparable.

• less freedom from significant long-term AI in the Yacoub group than the David group, which does not necessarily result in a higher reoperation rate in Yacoub group compared to the David group.

• favour of the David technique rather than the Yacoub technique in pathologies such as Marfan syndrome, acute type A aortic dissection, and excessive annular dilatation that may impair aortic root integrity.

• Careful selection of patients for each technique and successful restoration of normal cusp geometry are the keys to success in AVS operations.

Thank you

Left to right: remodeling, modified remodeling, sinus prosthesis, modified sinus prosthesis, reimplantation, and modified reimplantation.

In vitro hydrodynamics, cusp-bending deformation, and root distensibility for different types of aortic valve–sparing operations: Remodeling, sinus prosthesis, and reimplantationArmin Erasmi, MD, Hans-H. Sievers, MD * , Michael Scharfschwerdt, Thorsten Eckel, Martin Misfeld, MD, PhD

Department of Cardiac Surgery, University Clinic of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.

• Reimplantation of the aortic valve in a rigid tube leads to a nonphysiologic movement of the valve leaflets similar to that observed for stented bioprotheses, exposing the leaflets to

increased bending stresses and thus to the risk of premature failure. They maintain that this operation is adequate to avoid secondary dilatation of the aortic root and still to preserve or restore aortic valve function.

• Remodeling of the aortic root preserves some distensibility, with the propensity to reduce aortic outflow resistance and thus to lessen the load on the ventricle. It further allows for creation of a pseudosinus, allowing nearly normal opening and closing characteristics of the aortic valve and enhancing its durability [11, 12]. David and Feindel 8 have pointed out that, in extensive root dilatation, not only the sinuses of Valsalva are dilated but also the fibrous portions of the root inferior to the valve insertion line (ie, fibrous trigone and membranous septum). To correct the root also at this level, they have proposed mobilization of the root, anchoring a Dacron graft to the aortoventricular junction, and reimplantation of the aortic valve within the vascular graft.

• Nevertheless, debate still exists about which technique to apply to different pathologic conditions and, more generally, what there is to gain from using valve-sparing techniques compared with the standard composite prostheses. We therefore reviewed our 10-year experience with both types of valve-preserving techniques.

• Operative TechniqueAfter median sternotomy, standard cardiopulmonary bypass was initiated with a membrane oxygenator (Hollow Fiber Oxygenator, Spiral Gold, Baxter, Puerto Rico) using antegrade crystalloid or blood cardioplegia. Profound hypothermia (15° to 18°C) was used when circulatory arrest was necessary. The side of arterial cannulation was the femoral artery in 32 patients, the right subclavian artery in 5, a combination in 6, and the ascending aorta in a nondissected area in 121. Venous cannulation was performed through the right femoral vein in 9 patients and through the right atrium in the rest.

• The operative technique of the remodeling technique (group A) and the reimplantation technique (group B) has been described in detail [4, 5]. Briefly, the ascending aorta was transected 3 mm above the commissures. The sinuses of Valsalva were excised, leaving a 2-mm rim attached to the crown-shaped annulus. If the dissection affected the aortic root, gelatin-resorcin-formaldehyde glue (GRF; Cardial, Saint E'tienne, France) was used to readapt the dissected layers of the aortic wall before the sinuses were excised. The size of the tube used was determined by the distance between the straightened commissures giving a macroscopic picture of appropriate cusps coaptation and the diameter of the base of the aortic annulus, measured by means of a Hegar dilator [16].

• According to the adopted procedure, a trimmed or straight Hemashild Gold tube (Meadox Medicals, Oakland, NY), made with Dacron (DuPont, Wilmington, DE), was used to replace the excised sinuses. In some patients, one or more of the sinuses were macroscopically intact without any changes of the underlying pathology; only one sinus was replaced in 13 of these patients, and in 5 patients only two of the three sinuses were replaced using the surgical principles of the remodeling technique. In some patients of the remodeling group, we used our own technique of individual replacement of each sinus with a single piece of Dacron tube and additional replacement of the ascending aorta.

• In most of the patients, the distal anastomosis was performed in an open fashion using circulatory arrest

reimplantation technique caused significantly higher pressure gradients

Bending deformation indices for all valve-sparing techniques were more than twice those of the native aortic root and increased in relation to the degree the root was fixed with synthetic noncompliant material.

Aortic root distensibility, expressed as diastolic-to-systolic change of area, decreased in all surgical procedures compared with that of the native aortic root

Schematic drawing of measured aortic valve opening and closing characteristics of 3 distinct phases: a-b, rapid valve opening; b-c, slow systolic closure; and c-d, rapid valve closing movement. RVOT indicates rapid valve opening time; D1, maximal leaflet displacement; RVCT, rapid valve closing time; ET, ejection time; SCD, slow closing displacement; and D2, leaflet displacement before rapid valve closing.

Diagram of cyclic changes in dimensions derived from mean values of measured data at base, sinus, and commissural levels. Note reduced distensibility in group A at all levels of aortic root

Opening and Closing Characteristics of the Aortic Valve After Different Types of Valve-Preserving SurgeryRainer G. Leyh, MD; Claudia Schmidtke, MD; Hans-Hinrich Sievers, PhD, FETCS; Magdi H. Yacoub, PhD, FRCS

From the Departments of Cardiac Surgery, Medical University of Lübeck, Lübeck, Germany (R.G.L., C.S., H.-H.S.), and the National Heart and Lung Institute at the Imperial College of Science, Technology, and Medicine, London, UK (M.H.Y.).

EVOA is constant in both compliant and stiff roots

Aortic valve regional stresses in the normal aortic root and clinical valve-sparing models. *P = .0001 and {dagger}P = .0005 indicate significant difference as compared with the normal root model. b, Schematics of altered leaflet stress patterns in the graft models as compared with normal.

RE-CREATION OF SINUSES IS IMPORTANT FOR SPARING THE AORTIC VALVE: A FINITE ELEMENT STUDYK. Jane Grande-Allen, PhDa, Richard P. Cochran, MDb, Per G. Reinhall, PhDc, Karyn S. Kunzelman, PhDb

From the Department of Biomedical Engineering, Cleveland Clinic Foundation, Cleveland, Ohioa; Division of Cardiothoracic Surgery, University of Wisconsin, Madison, Wisb; and Department of Mechanical Engineering, University of Washington, Seattle, Wash.c

The Valsalva graft in aortic valve repair and replacement

Ruggero De Paulis1,*, Raffaele Scaffa, Stefano Forlani and Luigi Chiariello

Both techniques are widely used in the case of aortic root aneurysms associated with non-diseased aortic valves. The classic remodeling technique allows a good anatomical reconstruction of the sinuses of Valsalva but has a higher incidence of residual valve regurgitation. the classic reimplantation technique permits more stable results through annulus stabilization but completely abolishes the sinuses of Valsalva

Adapting the Valsalva graft to the patient's anatomy (I). When the height of the commissures matches the height of the ‘skirt’ the collar is cut out and the lower row of sutures are passed at the base of the skirt. In this way the top of the commissures will reach the level of the new sino-tubular junction (the connection between the two sections of Dacron)

Adapting the Valsalva graft to the patient's anatomy (II). When the height of the commissures is shorter than the height of the ‘skirt’ the collar is cut out and the lower row of sutures are passed at the corresponding level inside the skirt. The top of the commissures will therefore be at the level of the new sino-tubular junction.

Adapting the Valsalva graft to the patient's anatomy (III). In the rare cases when the height of the commissures is longer than the height of the ‘skirt’ the collar can be utilized to secure the lower row of sutures, to increase the length of the reconstructed root and to consent that the top of the commissures reaches the level of the new sino-tubular junction.

Because of its particular shape, the use of the Valsalva graft simplifies the surgical procedure by offering:•Decreased tension during coronary artery suturing•Decreased tension after graft pressurization•Increased anatomical adaptability•Decreased potential for suture bleeding and pseudoaneurysm formation•Easier access to the coronary anastomosis at the end of procedure

Remodeling of the aortic root combined to an expansible aortic ring annuloplasty

Standardized and physiological approach to aortic valve repair according to each phenotype of ascending aorta. (Reproduced from Ref. [17] with permission from Elsevier.)

Remodeling of the aortic root associated to an external subvalvular aortic annuloplasty (CAVIAAR technique), combining advantages of the original remodeling and reimplantation techniques: ‘remodeling’ technique provides the most physiological reconstruction of the root, but it does not address the dilated annular base. Alternatively, the reimplantation, as an inclusion technique, provides a subvalvular annuloplasty to the detriment of valve dynamics [6, 7, 9,10,11,12,13,14,15,16]. (Reproduced from Ref. [17] with permission from Elsevier.)

Criteria for the choice of the subvalvular aortic ring and Valsalva graft.

First step of valve repair: alignment of adjacent cusp free edges

Placement of the subvalvular expansible aortic ring (A) and final aspect of the aortic root (B). (Reproduced from Ref. [17] with permission from Elsevier.)

Placement of the five anchoring subvalvular ‘U’

stitches

Aortic root aneurysm for bicuspid valves: remodeling of the aortic root, resuspension of cusp effective height and subvalvular aortic annuloplasty.

• One hundred and eighty-seven patients underwent remodeling associated with a subvalvular aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated: Group 1: gross visual estimation (74 patients), Group 2: alignment of cusp free edges (62 patients), Group 3: two-steps approach associating alignment of cusp free edges with effective height resuspension (51 patients). A composite outcome was defined as recurrence of aortic insufficiency ≧grade 2 and/or reoperation. Operative mortality was 3.2% (20). Treatment of cusp lesion was most frequently performed in Group 3 (70.6%, vs. 20.3% Group 1 and 30.6% Group 2, P≪0.001). Nine patients required reoperation during follow-up [24 months (12–45)], from Group 1 (6) and Group 2 (3). At one year, no patients in Group 3 presented with composite outcome events (vs. 28.1% Group 1, 15% Group 2, P≪0.001). Residual aortic insufficiency and tricuspid anatomy were independent risk factors for composite outcome in Groups 1 and 2. Annulus diameter, Marfan syndrome and cusp repair had no effect on aortic insufficiency recurrence or reoperation [