Asian Cardiovasc Thorac Ann 2002;10:326-328
© 2002 Asia Publishing EXchange Pte Ltd
Combined Valve Operations with Transection of Ascending Aorta
Wang Wen Lin, MD,
Cai Kai Can, MD1,
Wang Wu Jun, MD1
Department of Cardiac Surgery Guangzhou General Military Hospital Guangzhou, Guangdong People’s Republic of China
1 Department of Cardiac Surgery Nanfang Hospital First Military Medical University Guangzhou, Guangdong People’s Republic of China
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For reprint information contact: Wang Wen Lin, MD Tel: 86 20 3622 4967 Fax: 86 20 3622 2315 email: willine{at}263.net Department of Cardiac Surgery, Guangzhou General Military Hospital, No. 111 Liuhua Road, Guangzhou, Guangdong 510010, People’s Republic of China.
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ABSTRACT
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To facilitate combined aortic and mitral valve operations, a new approach was developed. It was employed in 50 patients with both aortic and mitral valve disease. The ascending aorta was transected 1.5 cm above the aortic annulus, and the roof of the left atrium was incised. The damaged valves were replaced or repaired. Both aortic and mitral valves could be exposed satisfactorily by this approach. All patients recovered smoothly after the operation. Complications comprised intraoperative bleeding from the distal end of the ascending aorta in 1 patient and hoarseness in 3 postoperatively. The approach was considered quick and easy for combined valve operations.
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INTRODUCTION
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The current operation for combined aortic and mitral valve disease generally needs 2 separate cardiac incisions. While there are various approaches for mitral valve surgery, there is only one for an aortic valve operation, which is via an incision made anteriorly and laterally on the wall of the ascending aorta, with the posterior section left intact. It was speculated that if the aortic incision was extended to completely transect the ascending aorta, the mitral valve could be exposed through an incision in the left atrial roof. This could provide good access to both valves. To demonstrate the feasibility of this approach, we carried out an anatomical study on cadavers, with good results.1 Our early clinic experience also showed a favorable outcome.2
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PATIENTS AND METHODS
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From June 1998 to December 2001, 50 patients with aortic and mitral valve disease were chosen randomly for assessment of the new operative approach. There were 29 males and 21 females, their mean age was 51 ± 15 years (range, 27 to 68 years). After general anesthesia, with the patient in a supine position, a median sternotomy was performed. The distal ascending aorta was cannulated and a 2-stage venous cannula was inserted into the right atrium. Cardiopulmonary bypass was instituted and the patient was cooled to 28ºC. The ascending aorta was crossclamped and transected 1.5 cm above the aortic annulus. Cardioplegia was delivered directly into the left and right coronary sinuses to perfuse the myocardium. After achieving cardiac arrest, the two ends of the ascending aorta were retracted anterosuperiorly and anteroinferiorly. The pulmonary artery trunk and the superior vena cava were retracted laterally to provide good exposure of the roof of the left atrium. The left atrial roof was incised from the left wall of the superior vena cava to the base of the left atrium. The atrial incision and the proximal end of the ascending aorta were retracted anteroinferiorly to expose the mitral valve (Figure 1
). The damaged mitral valve was removed and a mechanical prosthesis was implanted (Figures 2 and 3). In some cases, mitral valvuloplasty was employed. The incision in the left atria1 roof was closed with 4/0 polypropylene suture. The damaged aortic valve was excised, and a mechanical prosthesis was implanted (Figure 4). Finally, the incision in the ascending aorta was closed securely with 3/0 polypropylene suture.
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RESULTS
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All 50 patients survived the operation. During surgery, mitral and aortic valves were satisfactorily exposed, which facilitated the operative procedure. Both replacement and valvuloplasty were used for managing the mitral valve problems, while only replacement was employed for the damaged aortic valve (Table 1). The total operative time was 167 ± 51 minutes, bypass time was 89 ± 27 minutes, aortic crossclamp time was 52 ± 9 minutes, and total hospital stay was 15 ± 5 days. Complications included bleeding from the distal end of the ascending aorta during the operation in 1 patient, and hoarseness in 3 others postoperatively. The intraoperative bleeding was controlled successfully by placing an additional crossclamp distal to the first one. The postoperative hoarseness disappeared within 3 months in all cases.
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DISCUSSION
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Exposure of the mitral valve is not always satisfactory because of its deep position. Several strategies have been employed to improve exposure, including retracting the venae cavae, extending the transseptal approach, and transecting the superior vena cava or the azygos vein.3 For an isolated mitral valve operation, any of these methods can facilitate exposure, but sometimes give rise to problems. As the ascending aorta is situated in front of the heart and relatively immobile, it is the main obstacle to good visualization of the mitral valve. Complete transection of the aorta and an incision in the left atrial roof would be expected to provide better exposure of the mitral valve, but the extra incision on the aorta would create an additional technical challenge, so most surgeons would avoid this approach for isolated mitral valve replacement. However, when an aortic incision is unavoidable, as in a combined mitral and aortic valve operation, it is reasonable to transect the aorta for the mitral valve operation. In the classic combined valve operation, the posterior wall of the ascending aorta is left intact, which not only hinders exposure of the mitral valve, but also obstructs the aortic valve. The natural position of the aortic annulus is nearly perpendicular to the operative plane. When the posterior aortic wall remains intact, forward traction on the incision cannot appreciably change the position of the aortic valve to improve visualization. With complete transection of the aorta and forward traction on its proximal end, the plane of the aortic annulus is parallel to that of the operative field, giving very good exposure of the valve.1,2 A similar approach was reported by Machiraju and colleagues3 who had satisfactory results. The mitral valve could be exposed well in all of our patients, and the extra "T" incision mentioned by Machiraju and colleagues3 was not employed in our series. We found that if an adequately long atrial incision was made, good mitral valve exposure was achieved, regardless of a small or large left atrium. The key to obtaining an adequate left atrial incision is to extend it to the base or even the body of the left atrium.
The primary concern in this approach is the safety of suturing both atrial and aortic incisions. If there was hemorrhaging from these incisions after weaning from cardiopulmonary bypass, it would be very difficult to stop, especially on the posterior wall of the ascending aorta. We recommend that the left atrial incision is closed before the aortic valve is replaced. Suturing should start from the left side of the incision because it is sometimes situated behind the pulmonary artery, then run to the right side where vision is always good, and knotted. Closure of the aortic incision should start from the mid point of the posterior wall. The suture distance should be no wider than 2 mm. A single layer of continuous polypropylene suture is adequate. No additional suturing was needed in this series, and no suture line bleeding occurred. Another concern with this approach is the method of reopening the atriotomy suture line if reexposure of the mitral valve should be needed after a double valve procedure. We suggest that reopening be performed by retracting the ascending aorta laterally. Removal of the aortic suture line should be avoided unless exposure is unsatisfactory, because re-suturing is time-consuming and technically difficult. We did not face this problem in any of our patients. During the operation, the distal end of the transected aorta should be clamped tightly to prevent sudden bleeding as in one of our patients. When the ascending aorta is dissected, the tissue posterior to it should be carefully protected because there is a possibility of injury to the recurrent laryngeal nerve. The postoperative hoarseness in 3 of our patients was considered to be related to such injury.
As these patients were not compared with a control group undergoing double valve replacement by the conventional approach, it is difficult to claim superiority for the new technique. Nevertheless, the method described seemed quicker and easier than the classic approach, despite the need for careful suturing of the aorta.
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REFERENCES
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- Wang WL, Zhong SZ, Wang WJ. Experimental study on approach for mitral and aortic valve operations with transection of ascending aorta [Chinese]. Chin J Regional Anat Operative Surg
2000;9:228–30.
- Wang WL, Zeng WS, Cai KC, Jiang RC, Wang WJ. Clinical experience in approach for mitral and aortic valve operations with transection of ascending aorta [Chinese]. Chin J Regional Anat Operative Surg
2001;10:110–1.
- Machiraju VR, Lima CAB, Culig MH, Bennett RD, Thakur NS. Exposure of the mitral valve by transecting the ascending aorta during aortic and mitral valve replacement. Ann Thorac Surg
2000;69:646–7.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
