Asian Cardiovasc Thorac Ann 2008;16:162-163
© 2008 Asia Publishing EXchange Ltd
Easy Technique for Placing Anchoring Sutures for Aortic Root Reimplantation
Hitoshi Ogino, MD,
Kenji Minatoya, MD,
Hitoshi Matsuda, MD,
Hiroaki Sasaki, MD
Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
For reprint information contact: Hitoshi Ogino, MD, Tel: 81 66 833 5012, Fax: 81 66 872 7486, Email: hogino{at}hsp.ncvc.go.jp, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan.
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ABSTRACT
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In the aortic valve-sparing reimplantation technique, insertion of the anchoring sutures beneath the valve is a crucial but difficult step because the spared aortic cusps obscure the field of view. We present a novel and easy method of placing these anchoring stitches with good exposure of the subvalvular tissue.
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INTRODUCTION
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Aortic valve-sparing surgery, represented by the reimplantation technique of David and Feindel1 or the remodeling procedure of Yacoub and colleagues2 is a routine and evolving procedure for annuloaortic ectasia or aortic root dissection, particularly in young patients with or without Marfan syndrome.3–6 In David’s reimplantation, passing the first-line horizontal mattress anchoring sutures from inside to outside the left ventricle, beneath the aortic valve, is an important but difficult step because the spared aortic cusps block the view of the subvalvular tissue. An easy way of exposing the subvalvular tissue for insertion of the anchoring stitches is described.
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TECHNIQUE
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The diseased aorta including the sinuses of Valsalva is excised leaving a 5 mm remnant of the aortic wall. The bilateral coronary buttons are constructed. The outside of the aortic root is dissected circumferentially to below the lowest portion of the aortic cusps. After measuring the aortic cusp height and diameter of the aortic annulus, the size of prosthetic woven Dacron tubular graft is decided. The first-line horizontal mattress anchoring sutures of 2/0 Ethibond (Ethicon, Inc., Somerville, NJ, USA) underneath each aortic cusp are passed from inside to outside the aortic root. In our modification, initially the 3 horizontal mattress stitches are passed at the mid portion underneath each aortic cusp. These double-armed stitches are retracted to compress the leaflet tissue (Figure 1
) to improve exposure of the subvalvular tissue for circumferential placement of the other stitches (Figure 2). The graft is positioned and the 3 commissures are attached to the graft following David’s original technique.1
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Figure 1. In placing the first-line horizontal mattress sutures underneath the aortic cusp from inside to outside of the aortic root, the 3 horizontal mattress stitches are initially passed at the mid portion underneath the aortic cusp; these three double-armed stitches are retracted for good exposure of the subvalvular space.
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Figure 2. The 3 cusps are compressed resulting in good exposure of the subvalvular tissue (surgeon’s view).
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DISCUSSION
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We used this technique in 7 consecutive patients with annuloaortic ectasia, of whom 4 had Marfan syndrome. Preoperative aortic insufficiency was trivial to grade I in 3, grade III in 1, and grade IV in 1. The prosthetic graft size was 26 mm in 2 and 30 mm in 5. All patients survived without major complications. Postoperative aortic insufficiency assessed by transesophageal echocardiography was trivial or less in all patients.
In David’s reimplantation, the circumferential placement of the first-line horizontal mattress sutures underneath the aortic valve is important as it determines the graft size and height of the 3 commissures. Without meticulous placement of the stitches, some deformity of the left ventricular outflow and the root could occur, resulting in poor balance and coaptation of the aortic cusps and commissures. Poor technique without good exposure might injure the aortic cusps. The method described herein can produce good exposure of the subvalvular space by retracting all the aortic cusps. Using this technique, it is easier to pass the first-line stitches precisely, and a well-balanced root structure with good coaptation of the aortic valve was obtained in these 7 patients, resulting in a satisfactory outcome without residual aortic insufficiency.
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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;103:617–22.[Abstract]
- Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg 1998;115:1080–90.[Abstract/Free Full Text]
- Kallenbach K, Oelze T, Salcher R, Hagl C, Karck M, Leyh RG, et al. Evolving strategies for treatment of acute aortic dissection type A. Circulation 2004;110(11 Suppl 1):II243–9.[Medline]
- de Oliveira NC, David TE, Ivanov J, Armstrong S, Eriksson MJ, Rakowski H, et al. Results of surgery for aortic root aneurysm in patients with Marfan syndrome. J Thorac Cardiovasc Surg 2003;125:789–96.[Abstract/Free Full Text]
- Birks EJ, Webb C, Child A, Radley-Smith R, Yacoub MH. Early and long-term results of a valve-sparing operation for Marfan syndrome. Circulation 1999;100(19 Suppl):II29–35.[Medline]
- Bethea BT, Fitton TP, Alejo DE, Barreiro CJ, Cattaneo SM, Dietz HC, et al. Results of aortic valve-sparing operations: experience with remodeling and reimplantation procedures in 65 patients. Ann Thorac Surg 2004;78:767–72.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
