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FIGURE 24.5 Aortotomies. (A) Transverse aortotomy (completed incision is total aortotomy). (B) Oblique S-shaped aortotomy. (C) Reverse-U-aortotomy.
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TABLE 24.3 Reverse-U-aortotomy (Kırali Incision)
1. Indications
a. Standard conventional AVR with all prosthetic types
b. AVR with hemisternotomy techniques
c. AVR after previous coronary artery bypass grafting with proximal anastomoses (no-touch technique)
d. Superior located right coronary artery
e. Severe calcification(s) on the way of standard aortotomy approaches
f. AVR with patient–prosthesis mismatch risk (small aortic root with appropriately sized aortic annulus)
g. Aortic root enlargement
i. posterior
ii. anterior
iii. combined
h. Second open-heart surgery for AVR
i. Supravalvular stenosis
j. Subaortic pathologies (IHSS, SDM)
2. Advantages
a. to adjust suitable distance from aortic valve and root (close or far according to prosthesis type)
b. to provide the most excellent exposure of the aortic valve,
c. to minimize dissection on the ascending aorta for aortotomy
d. to eliminate unnecessary dissection for severe adhesion of cardiac structure
e. to protect the whole posterior half of the ascending aorta intact
f. to avoid stretching and tension on the rest of the intact ascending aorta
g. to close aortotomy tension- and risk-free
h. to leave previous bypass conduits untouched
i. to supply antegrade selective cardioplegia easier through proximal anastomoses
j. to insert an appropriately sized stented aortic valve
k. to perform aortic annular enlargement
l. to allow sinus enlargement when aortotomy cannot be closed
AVR , aortic valve replacement; IHSS, idiopathic hypertrophic subaortic stenosis; SDM, subaortic discrete membrane.
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indication for this approach [51,52]. The initial transverse aortotomy is performed according to the surgery. If the AVR
is the first operation, the initial incision is made at least 2 cm above the STJ. If an AVR is performed after previous
CABG, the initial incision is made above or below proximal anastomoses leaving a minimum 2 cm distance from the
STJ (3 cm above the RCA). The incision is continued down at both sides to complete the incision such as a reverse
U-shape (as a tongue) (Fig. 24.5C). The medial edge of the initial incision is directed to the NCS, and the lateral edge
is targeted directly to the commissure between the left and right coronary sinuses, but terminating both ends above
the STJ. The tongue is retracted anteriorly with a 5/0 suture to exposure the aortic valve. This incision access in the
aortic root is very trouble free and straightforward because both distal ends of the incision are opposite to each other,
which means that the cardiac surgeon can access through the full diameter of the aorta just above the aortic valve,
which is the most important advantage of this approach over the other approaches when determining the appropriately
sized stented prosthesis (especially for low-profile bileaflet mechanical prostheses) to prevent PPM. If an annular
enlargement procedure is necessary, the medial incision is extended to the annulus or mitral valve for posterior annular
enlargement.
Valve Resection
Aortic valve stenosis occurs with fusion of one or both commissures, thickening, and retraction of the cusps with and
without calcification, and restriction of the aortic orifice. The calcification at the leaflets often extends to the annulus and
surrounding tissues. The most severe form is characterized by diffuse calcification of the aortic annulus and root (porcelain
aorta).
A surgically complete decalcification of the aortic annulus is the key step in the surgical AVR (Table 24.4) [24]. Unless
the aortic valve is noncalcific, aortic leaflets are cut by a scissor leaving a 3–4 mm margin at the annulus to hold replacement sutures securely. If the aortic valve is heavily calcified with healthy annular margins of the leaflets, the calcific aortic
valve is excised and trimmed with a scissor leaving a 2–3 mm margin at the annulus. A frequent scenario involves the
extensive calcification of the whole aortic annulus. Excision of the calcified leaflets with a scissor is usually unsuccessful
and dangerous because of possible breaking of calcifications resulting in falling calcium debris into the left ventricle. The
best approach to remove the diseased tissue is excision all leaflets with a lancet (number 15). A folded segment of sponge
or tampon is not necessary to place in the left ventricle and it hinders the visualization of the cavity and removal of calcium
particles. The easiest excision approach using the lancet is to perforate the healthy leaflet near the annulus in a partially
calcified aortic valve or to begin excision at the commissure between the noncoronary and right coronary leaflets in an
en-bloc calcified aortic valve. Cutting of the calcification is begun at the nearest end and the lancet incises the calcified
valve from the healthy annular tissue. The sharp edge of the lancet should be headed toward the calcified valve, and cutting is performed just below the calcification. The whole calcified valve must be excised en-block without fragmentation.
If calcification is very heavy or invades into the annulus it can be cut with the scissor and then the residual calcifications
can be gently crushed and removed with a rongeur. After completion of the aortic valve excision, all residual diseased and/
or calcified tissue or particles should be removed from around the annulus, for example, by a small curette. Before sizing
the prosthesis, the left ventricular cavity is flushed and irrigated with saline solution. During this step, if the calcification
has spread to the aortomitral curtain and anterior mitral leaflet it can be also removed simultaneously to mobilize anterior
leaflet.
The weakened area on the aortic annulus requires repair to prevent perforation, detachment, or postsuturing tears. If
the continuity is not fully disrupted, the weakened area must be secured between Teflon pledgets of anchor-sutures and the
sewing ring of the prosthesis. If any detachment occurs, a limited defect should be approximated with a 5/0 polypropylene
suture or a larger defect should be supported with pledgeted sutures.
TABLE 24.4 Decalcification Strategies of Aortic Annulus
1. not to leave any calcific tissue around the aortic annulus,
2. not to allow fragments of calcium to fall into the left ventricle,
3. not to disrupt the annulus if possible,
4. not to detach the anterior mitral leaflet from the annulus (noncoronary sinus),
5. not to rupture subannular muscular septum (right coronary sinus),
6. not to perforate outside the heart (left coronary sinus).
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Selection of Prosthesis-type
A bileaflet mechanical prosthesis is the gold standard for conventional AVR in patients younger than 60 years, but also in
any age group. The advantages are easy implantation techniques, long-term durability, better freedom from valve-related
adverse events and re-replacement, and safe use patients with in chronic diseases (i.e., renal failure, hypercholesterolemia,
hypercoagulable state, etc.). The disadvantages are a risk of PPM, lifelong anticoagulation, hemorrhage, risk of thrombosis
or stuck valve, and disturbing sounds.
Because mechanical prostheses have a smaller effective orifice area than the measured geometric orifice area, newly
designed valves with thinner sewing rings and larger inner diameters may solve PPM related-problems in patients with a
small aortic annulus. Supra-annular position, oblique implantation, supra-annular enlargement, or securing all sutures at the
NCS outside can be chosen to ensure the use of the appropriate size and prevent PPM. One of the more attractive approaches
is a posterior annular enlargement using a patch [53]. In the real world, a significant percent (approximately 40%) of the
cases has small aortic annulus and 19 or 21 mm valves are usually implanted to avoid an annular enlargement [54].
Biologic aortic prostheses are the first option considered in the older population to avoid anticoagulation-related
complications. Stented bioprostheses are the most commonly used valves due to ease of implantation, similar to stented
mechanical valves. Stentless valves without obstructive stent and strut posts are useful to prevent PPM, but also the newer
generation of stented bioprostheses has a larger effective orifice area. The best advantage of stentless bioprostheses is to
give an opportunity for TAVI after the stentless bioprosthesis degenerates and requires a reintervention. The advantages
include no need or contraindication for warfarin therapy, use in chronic hepatic disease, and improved long-term durability.
Noiseless function is usually the main reason for patients to prefer a bioprosthesis [55]. The main disadvantage is a structural degeneration, which requires a second operation.
Sutureless bioprostheses are the best option for high-risk patients and/or all types of minimal invasive AVR. They can be
implanted more easily (without suturing, smooth anchoring) and faster (cross-clamp time <15 min for implantation after aortic
valve resection) than the others, where cross-clamp time is reduced > 40% compared to procedures for implanting stented bioprostheses. Advantages include avoidance of full median sternotomy, shorter ischemic time, and avoidance of placing and knotting
sutures; however, the sutureless bioprostheses have the disadvantage of containing long equipments or paravalvular leakage.
Position of Prostheses
Position of a stented aortic prosthetic valve is very important to prevent a PPM, aortic tear, or unclosure of aortotomy
incision, which requires patch closure of aortotomy incision, aortic annular enlargement, or aortic root replacement
(Table 24.5). The less invasive solution is the oblique position of the stented prosthesis with external sutures on the NCS.
The preferred approach is the intra-annular anchorage of stented prosthesis with an appropriately prosthetic effective
orifice area. The best option for small aortic annulus is to prefer a stentless or sutureless bioprosthesis.
Techniques for Suture Insertion
Suturing of a prosthetic aortic valve is the key step of the AVR. All stitches should be placed deeply enough to strengthen
and secure the implantation. There are several approaches with their pros and cons (Fig. 24.6).
Stented Valves
The most commonly preferred suture technique for stented prostheses is interrupted suturing approach using 2/0 sutures (Fig.
24.7A); however, continuous suturing is usually not preferred (Fig. 24.7B). A total of approximately 18 single deeply biting
TABLE 24.5 Anchorage Techniques for Stented Prosthesis to
Prevent a Patient–Prosthesis Mismatch
1. Prosthesis with a thinned sewing ring
2. Supra-annular position
3. Oblique position
4. External sutures on the noncoronary sinus
5. Stentless or sutureless valves
6. Patch closure of aortotomy
7. Aortic annular enlargement
8. Aortic root replacement
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FIGURE 24.6 Suturing techniques. (A) Interrupted suturing. (B) Continuous suturing. (C) 8-shaped suturing. (D) Subannular pledgeted suturing.
(E) Supra-annular pledgeted suturing.
FIGURE 24.7 Suturing techniques without pledgeted support. (A) Single interrupted suturing. (B) Continuous suturing.
sutures along the annulus can be used to get a satisfactory anchorage of the stent either into or onto the aortic annulus. When the
aortic annulus is destroyed or too friable for anchorage, the related (or all) sutures should be supported with pledgets. There are
two methods for placing pledgets at the annulus: supra-annular position of pledgets is performed in an everted manner to put
the stent into annulus (Fig. 24.8A); subannular position of pledgets is more reliable due to buttressing effect, where the sewing
ring and pledget compress the weakened annulus from both sides as a sandwich (Fig. 24.8B). Subannular insertion of pledgets
has several advantages such as to facilitate supraannular valve implantation, to support annular defects, to repair aortomitral
discontinuity, and to purse up the thinned sinusal aortic wall on itself for the prevention of late aneurysmal growth.
Stentless Valves
The single suture line technique is a simple, quick, safe, and reliable method to replace the native aortic valve with a stentless valve [24]. In this approach, the device should fit the supra-annular area because the trimmed aortic wall of the stentless
valves is sutured and attached only with a proximal supra-annular suture line directly to native aortic sinuses in a supraannular position. Three 4/0 polypropylene sutures are started at the nadir of each sinus and brought progressively up to each
commissural tip with the ends brought outside the aorta for tying. Running sutures avoid any prosthetic dead space between
prosthetic valve and native aortic wall. This approach is used for implantation of the new generation scalloped tissue valves
in the supra-annular position. Because the stentless valve will be placed supra-annular, the selection of a prosthesis one size
larger than the native annulus minimizes the stress on the suture lines.
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FIGURE 24.8 Suturing techniques with pledgeted support. (A) Supra-annular position. (B) Subannular position.
Sutureless Valves
Without sutures, the implantation of an aortic prosthesis has been the goal procedure (Fig. 24.9). The new architectural design of
sutureless bioprostheses allows perfect function after it adapts itself to the aortic root. Avoidance of suture lines makes the procedure easier, and only transient guide-suture(s) may be required to ensure the correct positioning and orientation of the prosthesis.
A sutureless valve is stabilized in the aortic root with its root-like shape after anchorage to the aortic root in the Valsalva sinuses
or below the annulus with a cylindrical ring segment after it reaches a final diameter compatible with the aortic annulus.
OUTCOMES
Operative Mortality and Survival
Operative mortality rate has been decreasing in the last 50 years and has reached a plateau in the last decade. Operative
mortality changes for every age decade, sex, concomitant systemic diseases, previous valve surgery, and presence of
FIGURE 24.9 Sutureless technique.
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heart failure (Table 24.6) [56]. On the other hand, the Society of Thoracic Surgeon (STS) database has shown con-
tinual improvement in operative mortality of AVR with concomitant CABG from 6.3% in 2001 to 4.4% in 2010 [57].
The type of aortic prosthesis (mechanical or biological) has no impact on operative mortality. Most operative deaths
are related to several risk factors, including older age, functional status, neurologic complications, renal dysfunction,
pulmonary dysfunction, and infection.
Long-term survival has improved due to improvements in hemodynamically designed prostheses, which decrease transvalvular gradient and prevent late degeneration. Preoperative aortic pathology can affect long-term prognosis, and each
TABLE 24.6 Operative Mortality Rates for Isolated Aortic Valve Replacement
1997 2006
All 3.4% 2.6%
Timing
Elective 2.8% 1.9%
Urgent 6.5% 4.9%
Sex
Women 4.1% 3.2%
Men 2.8% 2.1%
Age
≤70 years 2.2% 1.3%
>70 years 4.6% 3.7%
Previous valve surgery
No 3.3% 2.4%
Yes 4.8% 5.6%
Congestive heart failure
No 2.1% 1.6%
Yes 5.2% 4.4%
Ejection fraction <30%
No 3.2% 2.4%
Yes 6% 5.2%
Renal failure
No 2.9% 2.2%
Yes 13.9% 8.5%
Age groups
<55 1.5% 0.9%
55–59 2.2% 0.6%
60–64 3.2% 1.6%
65–69 2.6% 1.9%
70–74 3.2% 2.9%
75–79 4.6% 3.3%
80–84 6.3% 4.9%
85–89 7.8% 4.1%
≥90 3.6% 9.6%
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survival data should be evaluated separately. Long-term survival rates for the heterogenous population are approximately
>95%, 75%, 60%, and 40% at 1, 5, 10, and 15 years, respectively. The longer survival rates have been published: 32%, 22%,
and 14% at 20, 25, and 30 years, respectively. However, 30-year freedom from valve related mortality is very successful
(≈75%) [54]. Long-term survival rates are slightly lower in the heterogenous population older than 70 years: >90%, >75%,
>45%, >40%, and >30% at 1, 5, 10, 15, and 20 years [58].
Pure severe AS treated with AVR (with or without concomitant CABG) has acceptable long-term survival rates but they
decrease in older patients (≥70 years): 88.6%, 71.6%, and 31.8% at 1, 5, and 10 years, respectively [59]. Predictors of longterm mortality are nonelective intervention, LVEF ≤ 40%, worse functional status, and older age. Every decade after 70 years
can impair approximate 1-, 5-, and 10-year survival rates: septuagenarians >90%, >75%, >45% [58]; octogenarians >90%,
>75%, and 21.7% [60,61]; and nonagenarians > 80% (and 46.2% at 2 years) [62]. On the other hand, patients with standard
severe AS have a better prognosis than those with paradoxical severe AS with or without low LVEF [63]. True-severe AS
with LVEF < 40% in younger population (mean age 55 years) benefits from AVR and for that reason they should undergo surgery in the earliest phase of left ventricular dysfunction to improve the long-term survival (83% and 60% at 5 and 10 years,
respectively), whereas preoperative worsening of left ventricular dysfunction affects the long-term survival [64].
Chronic severe AR treated with AVR (with or without concomitant ascending aorta replacement) has similar long-term
survival to an age- and sex-matched population: 96%, 90%, and 77% at 1, 5, and 10 years, respectively [56]. The main difference between subgroups relates to left ventricular dimension indices [cut points for indexed LVESD 2.5 cm/m2 (P < .001)
and indexed LVEDD 3 cm/m2 (P = .002)], but not depressed LVEF or increased left ventricular dimensions.
Stroke
There are many factors that can cause a transient or permanent neurologic deficits: particle or air embolizations, cerebrovascular disease, and low perfusion flow. Despite the decrease in stroke rate following isolated AVR to 1.3% patients with
older age (>75 years), renal failure or peripheral vascular diseases still have a 50% greater stroke risk than patients without
those predictors.
Complete Heart Block
Sinus node dysfunction, bundle branch blocks, or complete heart block may revert back to normal sinus rhythm during the
early postoperative period and also require temporary pacing. The requirement of a permanent pacemaker after AVR is a
rare (4.1%) but serious complication [65]. Debridement of a severely calcified aortic annulus and/or placement of deeper
sutures may damage the conduction system, especially in the bundle of His. Annular calcification, bicuspid aorta, female
sex, and presence of preoperative conduction defects increase this risk.
Postoperative Complications
The most common early postoperative complications include atrial fibrillation (37.8%), prolonged (>1 day) ventilation
(15.3%), low cardiac output (6.5%), and reexploration for bleeding (5.2%) [59]. Some late complications related to the
prosthesis (i.e., paravalvular leakage, prosthetic valve endocarditis, pannus formation, etc.) develop very rarely due to the
improvement of surgical techniques, new antibiotics, and new design of prostheses. Postoperative events related to warfarin
therapy are still the most significant complications that can cause death or severe neurologic deficits. Thirty-year freedom
from reoperation or endocarditis is very high (92%), but freedom from thromboembolism is acceptable (76%; 1.6%/patientyear); however, freedom from bleeding is serious (56%; 2.5%/patient-year) [54].
Anticoagulant-Related Late Complications
The most important complications during follow-up are related to chronic warfarin therapy: excessive anticoagulation may
cause severe hemorrhage in different organs, especially gastrointestinal or intracranial bleeding; too little anticoagulation
may result in thromboembolic events, including valve thrombosis. Mechanical prostheses with continuous warfarin therapy
are most at risk. Bileaflet mechanical valves in the aortic position need less anticoagulation than those in the mitral position,
and the valve thrombosis risk is also very low. Excessive warfarin may still lead to fatal bleeding during follow-up, and the
international normalized ratio for management of warfarin dosage should be held between 2 and 3 for mechanical aortic
prostheses. Anticoagulant therapy is discontinued in bioprostheses after the third postoperative month, which decreases the
risk of anticoagulant-related late complications.
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Structural Valve Degeneration
Primary tissue failure is the most important valve-related complication during follow-up. Structural valve degeneration (SVD)
means any abnormality in prosthetic function resulting from an intrinsic degeneration (i.e., stenosis, leaflet tears, suture line
disruption, calcification, etc.). The overall incidence of SVD is about 5% at 10 years, which is affected mostly by age. Age <60
increases early SVD threefold compared with older age, which can require a re-replacement, whereas age >70 is associated with
a higher rate of freedom from SVD and related reoperation [66,67]. Midterm results of stentless and sutureless bioprostheses are
better than stented bioprostheses, especially in small valves [10,68]. Despite the lack of data on long-term durability, stentless
or sutureless bioprostheses seem to be the preferred option of a biologic aortic prosthesis in patients aged <60 years because the
valve-in-valve procedure may be the most suitable and noninvasive treatment solution against a surgical reoperation.
FUTURE
Surgical AVR using the conventional approach (general anesthesia + full median sternotomy + stented valve implantation)
is still the gold standard, whereas minimally invasive approaches are often suitable and appropriate alternatives. ReverseU-shaped aortotomy is the best option to perform all kinds of operations for supra-annular, annular, and subannular aortic
pathologies. Every cardiac surgeon should appreciate the step-by-step learning curve of AVR: first conventional surgery
with stented valves, then stentless valves, then sutureless valves, and then minimal invasive approaches. There is currently
no place for transfemoral or transapical aortic valve implantations in patients due to significant risks. Clear guidelines are
available for treatment modalities in patients with isolated aortic valve diseases, but patient profile is the first determinant
in selecting the optimal intervention. The future will be built on the surgical approaches, implantation techniques, development of new prostheses, and more practical use of robotic systems. It seems that the optimum strategy for aortic valve
intervention may advance to a computerized surgery in future. Younger patients might benefit from bioprostheses as a result
of future improvements in prevention of structural degeneration, the valve-in-valve approach, and the shapable structure of
bioprostheses for minimal invasive surgery.
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