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Chapter 25
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Reconstructive Surgery of the Aortic Valve
Bartłomiej Perek, Sebastian Stefaniak
University of Medical Sciences, Poznan, Poland
Chapter Outline
Introduction: A Need to Preserve Native Valve 277
Anatomy and Pathophysiology—Crucial Considerations 277
Patient Selection—A Key of Surgical Success 278
Techniques for Aortic Valve Repair 279
Cusp Prolapse 280
Stress Fenestration 281
Cusp Perforation 281
Aortic Valve Retraction 281
Patch Material 282
Early and Long-Term Outcomes 282
Conclusions 283
References 283
INTRODUCTION: A NEED TO PRESERVE NATIVE VALVE
Aortic valve stenosis, the most common form of acquired valvular heart disease, is effectively treated by aortic valve
replacement (AVR) with either mechanical or biological prostheses [1]. Due to favorable early and late outcomes, this
therapeutic option has been considered as a method of choice for many years [1]. The implantation of the bioprostheses
may be performed minimally invasively with novel percutaneous techniques without cardiopulmonary bypass (transcatheter aortic valve implantation or TAVI). They have been gaining an increasing acceptance particularly in the elderly
and high-risk individuals within the last few years [2]. However, in 2007, Ozaki introduced a worthwhile method to
avoid the replacement of native aortic valve with artificial substitutes even in individuals with severe stenosis [3]. In
the last 2 years, his group has published a series of promising mid-term results in the various groups including dialysis
patients [4–7].
By contrast, subjects with aortic insufficiency (AI) have higher chances to undergo reconstructive procedures [8]. Easier
access to intraoperative transesophageal echocardiography, better understanding of the aortic valve dynamic anatomy, and
eventually absence of an ideal natural aortic valve substitute have encouraged to develop several surgical methods of repair
[9,10]. Inventors of aortic valve reconstruction claim that the conservative procedures are feasible in a large proportion
of subjects with isolated AI due to enlargement of the aortic root and/or cusp prolapse [11]. Although aortic valve repair
methods are technically more challenging compared to mitral valve reconstructions, the most experienced surgeons have
presented promising early and long-term results for many years [7,12]. Moreover, recently it has been proved the human
heart valves were living tissues and presented a capacity for growth and adaptation [13].
In this chapter, these methods and results of their clinical applications are presented. However, it should be highlighted
that only surgical techniques limited to aortic cusps or aortic annulus are presented below. Valve-sparing root replacement
techniques, either David reimplantation or Yacoub remodeling methods, are described at another place.
ANATOMY AND PATHOPHYSIOLOGY—CRUCIAL CONSIDERATIONS
All anatomical structures of the aortic root (the aortic cusps, the aortic annulus, the Valsalva sinuses, and the sinotubu-
lar junction (STJ)) (Fig. 25.1) play important roles to ensure central coaptation of the cusp and aortic valve competence
[14,15]. Each of the semilunar cusps has the base attached to aortic annulus and free margin that meet at the commissures
[14]. The cusps and corresponding sinuses are not of equal size in the human beings, the right one is usually larger than the
others [14,16].
New Approaches to Aortic Diseases from Valve to Abdominal Bifurcation. http://dx.doi.org/10.1016/B978-0-12-809979-7.00025-0
Copyright © 2018 Elsevier Inc. All rights reserved.
277
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FIGURE 25.1 Surgical anatomy of the aortic valve.
In many individuals with severe AI, the underlying mechanism is multifactorial and at least two structures of the aortic
root are involved. During reconstructive aortic valve surgery all of them should be addressed (so called pathology-directed
approach). Failure to fix appropriately even one of them will probably result in recurrent AI and a need for repeat surgery
within the follow-up period.
PATIENT SELECTION—A KEY OF SURGICAL SUCCESS
A proper patient selection on the base of clinical and echocardiographic findings is crucial to achieve permanent suc-
cess. Roughly, the optimal candidate should be relatively young or middle-aged without concomitant cardiac pathologies
requiring simultaneous correction and should have pliable cusps. Elderly individuals and patients with many comorbidities
should rather undergo simpler procedures of AVR, preferably with sutureless prostheses [17,18]. Exception may be Ozaki
method applicable with promising results also in the elderly [4,6,7]. Not only age, expected life span, or clinical status but
also cardiac surgical experience of a given center should be taken in consideration before a final decision to perform reconstructive procedure on the aortic cusps [19]. According to the American Heart Association guidelines, aortic valve repair
procedures should be considered only in those surgical centers that have developed the appropriate technical expertise,
gained experience in patient selection, and demonstrated outcomes equivalent to those of valve replacement [20].
There are accepted anatomic contraindications to aortic valve repair for AI such as extensive leaflet damage and severe
calcifications.
El Khoury group from St. Luc Hospital, Brussels, an expert team in aortic valve repair, has introduced simple repairoriented classification of AI [8]. It may support the decision if aortic valve repair should be considered. They have distinguished the following types of AI:
l Type 1: normal cusp motion but dilatation of the aortic root and/or ascending aorta (reparable with David or Yacoub
procedures);
l Type 2: excess cusp motion (prolapse), good cusp tissue quality (amendable to be corrected with cusps repair techniques);
l Type 3: cusp retraction, poor cusp quality, extensive calcification or endocarditis (rather irreparable although Ozaki
method might be applicable).
Another practical classification was proposed in 2008 by Lansac and colleagues (Fig. 25.2) [21]. The aim of this classification was to standardize surgical management in a given pathology associated with severe AI and in a consequence
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FIGURE 25.2 Lansac classification standardizes aortic valve repair techniques. Lansac classification standardizing repair techniques is a useful tool
supporting the surgeon’s intraoperative decisions.
widespread of the reconstructive techniques. Aortic valve pathologies are divided on the basis of jet characteristics. Type I
is reserved for central jet, type II for eccentric jet. In general, patients with type I lesions undergo aortic root or ascending
aorta replacement, whereas in type II lesions any repair of aortic cusps must be addressed.
Irrespective of the classification applied to support therapeutic decisions, aforementioned information is derived from
careful analysis of the imaging studies, particularly echocardiography and direct inspection during surgery. Thus, close
cooperation between the surgeon and cardiologist–echocardiographer is essential to determine the exact mechanism of AI
and it markedly increases the likelihood of successful and durable aortic valve reconstruction.
TECHNIQUES FOR AORTIC VALVE REPAIR
A number of conservative procedures have been described to reconstruct aortic valve. Some of them are done as separate
procedures, whereas the others are just a part of more complex cardiac surgical operations on the aortic root. Concerning
the aortic cusps only, four principal pathologies such as prolapse, stress fenestration, tear/perforation of the cusp body,
retraction (incompetent severely damaged misshaped valves) are usually distinguished.
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In adult patients, the most commonly performed aortic valve reconstructive surgeries are on incompetent bicuspid aortic
valves or valves rendered incompetent as a result of excessively dilated aortic root and/or ascending aorta.
Cusp Prolapse
Normal cusps of the aortic valve coapt approximately at halfway between the aortic annular base and the STJ. Cusp is
defined as prolapsing if its free margin moves below this level. It is usually cased by elongation of the free margin. Surgical
technique to solve this problem depends on morphology of the “cusp tissue.” If the cusps are thin and macroscopically
normal, which is generally seen in the tricuspid aortic valve (TAV), prolapse correction is done by means of free margin
plication along the nodule of Arantius (i.e., central cusp portion) or cusp resuspension or both of them. Although they were
described many years ago [22,23], particularly plication method, they became more commonly applied in the era of aortic
valve repair [10]. The cusp plication is performed with a fine (5-0 or 6-0) monofilament suture passed through the free
margin and then extended perpendicularly, usually a few millimeters, from the free margin toward the body of the cusp
[24]. This maneuver decreases cusp distension, restores its natural shape, and eventually elevates its free margin to the
level of coaptation. Another one, free margin resuspension technique designed by David is carried out with fine expanded
polytetrafluoroethylene (ePTFE) sutures (Gore-Tex) weaving with a double layer along the entire length of the free margin
from one commissure to another one (Fig. 25.3) [25]. Applying correct tension on both suture arms, the shortening of the
elongated free margin of aortic cusp is obtained. The ends of ePTFE suture are anchored on the outside of aortic wall or
on the Dacron graft if resuspension is a part of reimplantation of the aortic valve [26]. Resuspension is recommended if
free cusp margins are fragile or all cusps present symmetric prolapse [10]. It is also preferred to fix stress fenestration in
the commissural area additionally to prolapse repair. However, in BAV patients, the shortening of the free cusp margin, if
applicable, should be proceeded by resection of the raphe of the conjoint cusp. If the aortic cusps are thickened, triangular
resection of the prolapsing area is preferred. Fibrosis and calcification of the prolapsing cusp are seen more frequently in
BAV patients, particularly if raphe is present. In some cases, a patch must be sutured to repair the defect [27].
Dilatation of the aortic annulus, also called the ventirculo-aortic junction (VAJ), is often an accompanying aortic root
pathology [28]. Aortic annulus repair does not only reduce its actual diameter but also prevents from secondary dilatation.
It results in a decrease in stress on the cusps and eventually protects the cusps reconstruction. Currently, no universal technique for plication and stabilization of the dilated aortic annulus exists [29]. The first method was external suture placed
around the annular base on a beating heart [30]. Cabrol and colleagues proposed plicating mattress stitches reinforced with
Teflon felt pledgets that could be placed over or below commissures, on the outside of the aortic sinuses wall or on the
inside of the aortic root [31]. Aforementioned methods are considered to be incomplete and may have a negative impact
on proper aortic root geometry and valve dynamics. Not only cases of sutures migration have been reported [32] but also
subcommissural annuloplasty (Cabrol stitch) was noted to be insufficient for the prevention of further VAJ dilatation [29].
Thus, annuloplasties involving a whole length of aortic annulus with a circular suture or ePTFE bands of glutaraldehydefixed pericardial strips have been proposed [33,34]. A few years ago, an internal prosthetic ring sutured to the STJ with a
strip along the fibrous annulus was designed [35]. However, all aforementioned complete annuloplasty techniques did not
take into account dynamics of aortic root associated with heart cycle and instant movement of all structures. Lansac and
FIGURE 25.3 Resuspension of aortic cusp free margin. A fine (usually 6-0 or 7-0) polytetrafluoroethylene (Gore-Tex) suture is weaved along the free
margin of the aortic cusp (A) and secured on the outside of the graft (B) used for reconstruction of the aortic root.
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FIGURE 25.4 Lansac subvalvular annuloplastic ring. LCA, left coronary artery; LCC, left coronary cusp; RCA, right coronary artery; RCC, right
coronary cusp; STJ, sinotubular junction.
colleagues designed a new expansible open aortic ring to achieve a complete and calibrated annuloplasty in diastole, while
maintaining expansibility of the aortic root in systole (Fig. 25.4) [36].
Many individuals undergoing repair of prolapsing cusps have also valve-sparing procedures. For example, in David
experience, more than 40% of patients who underwent reimplantation of the aortic valve had cusp plication [28]. In the
another study, free margin resuspension was done in one-fifth of David reimplantation subjects [37].
Stress Fenestration
Predominant mechanism of stress fenestration is dilatation of the STJ that increases the mechanical stress along the free
margin of the aortic cusp that becomes ovestretched. Eventually, it may result in cusp fenestration in the commissural area
or even detachment from the aortic wall. This type of pathology is usually corrected together with aortic cusp prolapse
applying resuspension technique (see above). Double layer of fine (usually 6-0) PTFE suture along the free margin of the
cusp is appropriate to fix both prolapse and stress fenestration [10]. In the past, commissural plication sutures were applied
to treat fenestration but due to rather disappointing long-term results they are not recommended.
Cusp Perforation
In the selected group of patients, cusp perforation may be the only cause of severe AI. It can be caused by aortic valve endocarditis or iatrogenic (accidental or following cusp tumor resection). However, iatrogenic cusp perforation during intravascular cardiologic or cardiac surgical procedures is very rare [38,39]. If endocarditis is in the active phase, reconstruction of
the aortic cusp is not recommended. In other cases, cusp perforation is accomplished by a patch around the defect with a
fine monofilament suture [11].
Aortic Valve Retraction
In patients with aortic valves rendered incompetent and/or stenotic by congenital or rheumatic disease, reconstructive valvular surgery is controversial. In the majority of cardiac surgical centers, AVR still remains the gold standard. Aortic valve
repair is performed exclusively by the most experienced cardiac surgeons. Two major techniques such as cusp extension or
aortic valve neo-cuspidization (Ozaki method) deserve to be mentioned.
Cusp extension with patch that is sutured to the remaining cusp tissue either at its base or its free margin may be carried
out in a limited group of patients. However, it is practically limited to the treatment of patients with AI irrespective of the
underlying pathology [40,41]. Sometimes patients with BAV have AI due to restriction of the conjoint cusp and in them
patch enlargement is recommended during reconstructive surgery of the aortic valve. Moreover, a pericardial patch can also
be used to repair unicuspid aortic valve transforming it into a bicuspid one [37].
Contrary to the aforementioned one, a technique designed by Ozaki can be applied in a wide spectrum of pathologies
including also aortic stenosis, infective endocarditis on native valves and even on the prostheses [3]. During the first stage
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of surgery, autologous pericardium is prepared, a patch of appropriate size is excised and treated in 0.6% glutaraldehyde for
10 min. After native cusps removal, the distance between each commissures is measured with the Ozaki sizer (Ozaki VRec
sizer) and the new leaflets of the appropriate sizes are trimmed from glutaraldehyde-treated autologous pericardium. Then
the annular margin of the pericardial leaflet is sutured with a 4-0 monofilament to each annulus and commissural coaptation
is secured with additional 4-0 monofilament sutures. Eventually, the coaptation of three new leaflets is checked under direct
vision before closure of the aortotomy.
Although we must wait a few more years for the long-term results, this method seems to be a promising one as may be
applied in the elderly who predominates among aortic stenotic patients in the developed countries.
Patch Material
Patches to extend aortic cusps are usually made of autologous or bovine pericardium [42]. Autologous one may be fresh
or preserved in glutaraldehyde (e.g., in Ozaki method) [3]. Bovine pericardium must be fixed. Although glutaraldehydepreserved patches are widely applied other fixation techniques, for example, dye-mediated photooxidation (PhotoFix, Sorin
CarboMedics, Italy) has been also proposed [43].
Enormous progress in medical technology resulted in the introduction of decellularized materials. Decellularized porcine intestinal submucosa extracellular matrix (CorMatrix ECM Technology, USA) has been used in cardiac and vascular
surgery for 2 years and only preliminary results of its application are available [44,45]. The latest experiments in a sheep
model showed that decellularization of pericardium used for patch repair might improve durability [46].
EARLY AND LONG-TERM OUTCOMES
Although reconstructive aortic procedures are complex, intraoperative mortality is minimal [10,42,47,48]. At least two
factors have an impact on such excellent results. First, patients undergoing such operations are carefully selected. They are
usually young and generally healthy [49]. Additionally, they are treated by the best and the most experienced worldwide
recognized cardiac surgeons. A propensity-matched analysis comparing aortic AVR, considered as the standard and safe
procedure, with repair showed no differences in operative mortality [50].
Overall survival is favorable with approximately 90% and 80% at 5 and 10 years, respectively [47]. In the aforementioned propensity-matched study, aortic valve repair was even noted to improve late survival in comparison with AVR [50].
Compromised left ventricular systolic performance defined as ejection fraction below 50% and left ventricular end systolic
dimension larger than 55 mm were found to impact negatively on the survival rate [47].
Durability of aortic valve repair procedures is determined by the function of valve assessed by the means of transesophageal echocardiography just after weaning from cardiopulmonary bypass [51,52]. The postrepair grade of AI corresponds
with the long-term success [51]. The aortic cusps must coapt above the nadir of the aortic annulus and have an appropriate
amount of coaptation area [11]. In El Khoury group of TAV patients, freedom from reoperation for recurrent severe AI at
3 years was 100% for cusp plication, 92 ± 8% for cusp free margin resuspension, and 89 ± 11% for plication combined with
resuspension, respectively. However, it must be stressed that plication was applied as the first choice method, whereas free
margin resuspension was done in more complex pathologies [10]. More complex valve repair was found to be one of a
predictor of repair failure and reoperation [48]. In BAV subjects, results were shown to be more variable but usually slightly
worse than in TAV patients. Casselman and colleagues found plication of prolapsing BAV was associated with approximately 80% freedom from reoperation at 8 years and existence of AI in early postoperative echocardiography was the only
independent risk factor [53]. In the Cleveland Clinic experience, 24% of patients had severe AI at 5 years of follow-up [54].
Contrary to them, Bavaria and colleagues reported excellent outcomes with a 100% freedom from mortality and aortic
valve reintervention at 5 years [49]. A crucial distinction between them was a rate of concomitant procedures on the aortic
root, 100% in Bavaria group, and only 38% in the Cleveland Clinic one. Thus, reinforcement of aortic annulus during valvesparing root replacement with the implantation technique, although causing surgery to be more difficult usually provides a
more stable repair of incompetent BAV [48].
Some reports advocated that cusp extension with patches was associated with a higher risk of reoperation due to recurrent AI [55]. Generally, freedom from reoperation after patch repair procedures is around 95% at 1 year, 85% at 5 years,
80% at 10 years, and 75% at 15 years [56]. In the another study, reoperation rate throughout the first 5 years following surgery was approximately 4.0% per patient-year [42]. Studies comparing late results after patch repair with respect to patch
material showed that the application of glutaraldehyde-preserved pericardium was linked to the higher risk of reintervention
for recurrent AI than autologous pericardium [42,55,56]. Finally, long-term results of pericardial extension of the aortic
cusps are similar to those of AVR with bioprostheses [57].
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Slightly worse outcomes were reported for patients with unicuspid aortic valve after bicuspidization with patch.
Estimated freedom from reoperation for recurrent AI was about 80% at 5 years [58].
Ozaki procedures, different than the others, are also safe and durable [7]. In his group of more than 400 cases, in all
except two less than mild aortic regurgitation was observed. Freedom from reoperation exceeded 96% at 4.5 years of
follow-up.
Aortic valve repair procedures, including Ozaki operations, have been shown to be associated with a very low
incidence of thromboembolic adverse events and infective endocarditis, significantly lower than those rates noted
after standard operations of AVR [7,8,59]. It is of particular importance in young adults. Additionally, long-term
anticoagulation is not necessary. Thus, the risk of anticoagulaton-induced excessive bleeding is minimized. It also
enables to avoid additional risk associated with planned medical procedures including open surgeries or unexpected
trauma.
Despite many benefits of aortic valve repair procedures, we must be aware of some disadvantages. Unfortunately, reoperation of recurrent AI is indicated in up to 20% of patients at 8–10 years after primary surgery [53,56]. The repeat surgeries
are technically challenging and are usually associated with prolonged cardiopulmonary bypass and aortic cross-clamping
time and reduced survival rate.
CONCLUSIONS
The majority of reconstructive procedures on the aortic valve are applied in young or middle-aged patients with AI. Pretty
often accompanied pathology of the other components of the aortic root must also be addressed. Thus, these operations
are usually performed by the most skillful and experienced cardiac surgeon. The only reconstructive procedure that can be
done with a high rate of success in patients with aortic stenosis is the Ozaki procedure. However, in the future it will have
to compete with minimally invasive interventions (TAVI).
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Chapter 26
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Aortic Root Replacement
Kaan Kırali1, Sabit Sarıkaya1, Deniz Göksedef
1
Koşuyolu Heart and Research Hospital, Istanbul, Turkey; 2Istanbul University, Istanbul, Turkey
2
Chapter Outline
Historical Perspective 287
Indications for Aortic Root Surgery 288
Initial Stages 288
Anesthesia 288
General Anesthesia 288
High Thoracic Epidural Anesthesia 288
Sternotomy and Cannulation 289
Full-Median Sternotomy 289
Ministernotomy Techniques 289
Prosthetic Valve 290
Operative Techniques 290
Total Aortic Root Replacement Procedures 291
With Aortic Valve Replacement 291
With Aortic Valve Sparing 296
Subtotal Aortic Root Replacement Procedures 298
One-Sinus Replacement Technique 298
Two-Sinus Replacement Technique 300
Sinus of Valsalva Aneurysm Repair Techniques 300
Extensive Aortic Root Replacement Technique 300
Outcomes 301
Bentall Procedures 301
Remodeling or Reimplantation 302
Extensive Aortic Root Enlargement 302
Future 302
References 302
HISTORICAL PERSPECTIVE
The history of aortic root surgery started with ascending aortic procedures. Although not a true total aortic root replacement (ARR) procedure, the first aortic root surgery operation performed by Wheat and colleagues [1] included aortic valve
replacement (AVR) and supracoronary ascending aorta replacement separately. The first true total ARR procedure performed
by Bentall and DeBono [2] contained en bloc replacement of the proximal aorta, known as the “Classic Bentall Operation.”
Modified Bentall techniques using a mechanical or biological prosthetic valve, which eliminated wrapping of the native aortic wall over the tubular graft, are now preferred over complete ARR. Finally, the coronary button reimplantation technique
via end-to-side anastomosis reported by Kouchoukos and Karb [3] eliminates most of the problems regarding coronary ostial
anastomoses and has become the gold standard procedure for the total ARR, known as the “Button Technique.” An alternative coronary anastomosis technique reported by Cabrol and colleagues [4] includes a graft positioned between the coronary
ostia and tubular graft to prevent coronary malposition, which is especially useful in aortic root reoperations because of the
often difficult or impossible mobilization of the coronary buttons. Closing aortotomy to wrap whole prosthetic composite
graft reapplied by Kawazoe and colleagues [5] is popularized again to minimize bleeding or development of pseudoaneurysm. Other modifications include leaving a small part of the tubular graft below the prosthetic valve to simplify and secure
proximal aortic annular anastomosis with/without any subannular reconstruction of left ventricular outflow tract (LVOT)
defects [6–8]. To simplify proximal annular anastomosis during ARR with a composite graft, several prefabricated composite grafts with/without sinus of Valsalva have been introduced and are now used worldwide [9].
The goal of aortic valve–sparing root replacement procedures is preservation of native aortic leaflets to avoid prosthetic
valve–related complications, while replacing the entire diseased proximal aortic wall to treat aortic root pathology. The
Standard remodeling technique developed by Yacoub [10] conserves the native aortic valve and re-creates aortic sinuses
during total ARR without annular stabilization. The Reimplantation technique developed by David [11] also conserves the
native aortic valve but stabilizes the aortic annulus and re-creates neo-pseudosinuses. The standard reimplantation technique (David I) cannot re-create aortic sinuses and aortic root geometry, but several modifications have resulted in refinement and the current method, David V, re-creates neo-pseudosinuses. Another alternative to re-create neo-pseudosinuses
is reimplantation of the aortic root wall with a Valsalva tube graft, which can also provide annular and sinus stabilizations
New Approaches to Aortic Diseases from Valve to Abdominal Bifurcation. http://dx.doi.org/10.1016/B978-0-12-809979-7.00026-2
Copyright © 2018 Elsevier Inc. All rights reserved.
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