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N. Moorjani et al.
Inferior Leaet Imbrication Stitch
Here the inferior leaet is excluded with robust sutures
through the annulus at either end of the leaet which when
Fig. 14.7 Inferior leaet
imbrication. Here the inferior
leaet is excluded with robust
sutures through the annulus at
either end of the leaet which
when tied excludes the leaet
and that part of the orice
from the inow of the valve
tied excludes the leaet and that part of the orice from the
inow of the valve (Fig.14.7).
14 Tricuspid Valve Disease Techniques
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111
Anterior Leaet Augmentation
withPericardium
In this technique, a generous patch of pericardium is sewn
onto the detached annular portion of the anterior leaet. It is
important to use a patch at least one third bigger than the
Fig. 14.8 Anterior leaet
augmentation with
pericardium
Line of incision
AL
SL
defect when stretched open to allow for shrinkage of the
pericardium with the passage of time. It also gives a generous height of coaptation to the leaets. An annuloplasty partial band is then placed in the usual way (Fig.14.8).
PL
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N. Moorjani et al.
Sub Valve Repair Techniques
As with the mitral valve occasionally, there are cordal ruptures and papillary muscle avulsions in the tricuspid valve.
These can be addressed in the same way as in the mitral
valve with the insertion of neo-cords, usually with Gore-Tex
sutures. This is commonly the situation encountered in
trauma cases reconstruction is desirable, as valve replacement on the right side is usually relatively short lived with
early valve failure (Fig.14.9).
1
References
1. Naja I, etal. Traumatic tricuspid regurgitation. J Cardiovasc Surg.
1992;33:256.
2. Maisano F, Lorusso R, etal. Valve repair for traumatic tricuspid
regurgitation. Eur J Cardiothorac Surg. 1996;10:867–73.
3. Dreyfus GD, Martin RP, Chan KM, Dulguerov F, Alexandrescu
C. Functional tricuspid regurgitation: a need to revise our understanding. J Am Coll Cardiol. 2015;65(21):2331–6.
4. Tornos Mas P, Rodriguez-Palomares JF, Antunes M. Secondary
tricuspid valve regurgitation: a forgotten entity. Heart.
2015;101:1840–8.
Suggested Reading
Tang GHL, David T, Singh S, etal. Tricuspid valve repair with an annu-
loplasty ring results in improved long-term results. Circulation.
2006;114:I577–81.
Tsuchida K, et al. Right coronary artery stenosis associated with
tricuspid valve ring annuloplasty. Cardiovasc Interv Ther.
2017;32(4):420–4.
2
3
4
Fig. 14.9 Sub valve repair techniques (1 through 5)
Tricuspid Valve Replacement
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NarainMoorjani
15
In patients with extensive disease of the tricuspid valve
where repair is not feasible, such as marked leaet tethering,
retraction or calcication with rheumatic valve disease
(Fig.15.1a), or carcinoid, replacement of the valve is indicated. The choice between a mechanical or biological stented
valve remains controversial. Although both have similar outcomes for survival, mechanical valves are prone to thromboembolic complications in the low-pressure right-sided
circulation. Although mechanical valves are thought to have
a greater durability, there is evidence of good long-term
durability of a tricuspid valve bioprosthesis in the lowpressure right-sided circulation, even in relatively young
patients.
Interrupted pledgeted non-everting 2/0 Ethibond sutures
are placed along the annulus, from the right ventricle into the
right atrium, with approximately 8–10 mm between each
limb of the suture and 1 mm spacing between adjacent
sutures (Fig.15.1b). It is important to place the sutures vertically into the myocardium and not horizontally into the atrial
or septal tissue. The depth of suture placement needs to be
sufcient so that the suture does not tear through. Knowledge
of the anatomical position of nearby structures, such as the
right coronary artery, aortic valve, conduction tissue or coronary sinus is essential. At the superomedial aspect of the septal annulus, sutures are placed through plicated septal leaet
tissue to avoid the conducting tissue, which lies at the apex
of the triangle of Koch. The valve orice is then measured,
using the sizers provided by the manufacturers. The sutures
are placed through the sewing ring, and the prosthesis is the
tied down. When tying down the sutures for a stented biological valve, it is important to ensure that the sutures do not
get trapped around the stents of the prosthesis. Certain bioprostheses come with a guard to reduce the risk of this occurring (Fig.15.1c). A bioprosthetic tricuspid valve is orientated
with the stents aligned with the anteroseptal and the posteroseptal commissures (Fig.15.1d). A mechanical prosthesis is
orientated in an anti-anatomical position, so that the maximum ow is directed into the right ventricular outow tract.
Prior to closure of the right atriotomy, it is important to
ensure both mechanical and tissue leaets of the prosthesis
open and close properly.
N. Moorjani (*)
Department of Cardiothoracic Surgery, Royal Papworth Hospital,
Cambridge, UK
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. C. Wells (ed.), Atlas of Cardiac Surgery, Springer Surgery Atlas Series, https://doi.org/10.1007/978-3-031-43195-1_15
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114
cd
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N. Moorjani
a
b
Fig. 15.1 Operative images demonstrating a tricuspid valve replacement, with (a) a rheumatic tricuspid valve characterised by brotic,
retracted leaets, and rolled up free edges, (b) implantation of the valve
replacement sutures, using a non-inverting horizontal mattress 2/0
Suggested Reading
Anselmi A, Ruggieri VG, Harmouche M, Flécher E, Corbineau H,
Langanay T, Lelong B, Verhoye JP, Leguerrier A. Appraisal of long-
term outcomes of tricuspid valve replacement in the current per-
spective. Ann Thorac Surg. 2016;101:863–71.
Ethibond sutures, plicating any residual leaet tissue; (c) parachuting of
the prosthetic valve down to annulus, with the protective guard in situ
to prevent the sutures getting caught around the struts; (d) tricuspid
valve bioprosthesis in situ, following tying down of the sutures
Dreyfus J, Dreyfus GD, Taramasso M.Tricuspid valve replacement: the
old and the new. Prog Cardiovasc Dis. 2022;72:102–13.
Hwang HY, Kim KH, Kim KB, Ahn H.Propensity score matching
analysis of mechanical versus bioprosthetic tricuspid valve replacements. Ann Thorac Surg. 2014;97:1294–9.
Part V
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Surgery of the Aorta
Aortic Arch andAscending Aorta
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Replacement
RaviJ.de Silva
16
The development of aortic arch surgery credits many of the
doyens in our relatively young surgical speciality. In 1957,
Michael DeBakey described the rst aortic arch replacement.
The use of deep hypothermia and circulatory arrest to facilitate
arch surgery was pioneered by Griepp in the 1970s, and then
Hans Borst of Hanover introduced the elephant trunk into our
surgical lexicon. This involves leaving a free- oating vascular
graft in the patient’s native descending aorta at the time of arch
replacement. The technique was further modied by Crawford
and Svensson in the 1990s and has since been superceded by
the frozen elephant trunk, which replaces the free-oating vascular graft with a covered stent deployed into the descending
aorta. At Papworth, we have the largest experience of frozen
elephant trunk (FET) arch replacement in the UK. Terumo
Aortic and Artivion each produce a FET device (Fig. 16.1),
either of which can be used in the technique we describe.
Despite advances in medical technology and surgical
techniques, the aortic arch remains a relatively hostile surgical environment. Vital adjacent neurovascular structures
invite complications such as stroke, limb ischaemia, recurrently laryngeal nerve palsy, mesenteric ischaemia, and paraplegia. The technique described below aims to minimise the
risk of these potentially devastating complications.
Replacement of the ascending aorta often accompanies
replacement of the aortic arch, although the reverse is less so.
Contributions of Denton Cooley to the eld of aortic surgery
cannot be over stated. He was the rst to report replacement
of the ascending aorta using a homograft in 1956, and his
subsequent endeavours lead to creation of the prosthetic vascular grafts we use today.
Guidelines for the surgical management of the ascending and arch of aorta are published and periodically revised
in Europe and North America (EACTS and AATS, respectively). Briey, a maximum diameter of more than 55mm
or a rapid increase in size (>1cm in 6months) in patients
without connective tissue disorders is an indication for
elective surgery. For patients with connective tissue disease, the aorta may warrant surgery at smaller dimensions
depending on the natural history of the disease. Emergency
surgery may also be indicated in acute aortic syndromes
and trauma, and is also detailed extensively in the previously mentioned publications. We nd a multidisciplinary
approach with cardiologists, vascular surgeons, interventional radiologists, and cardiac surgeons is essential when
deciding the appropriate management of these complex
patients.
R. J. de Silva (*)
Department of Surgery, Royal Papworth Hospital NHS Foundation
Trust, Cambridge, UK
e-mail: ravidesilva@nhs.net
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. C. Wells (ed.), Atlas of Cardiac Surgery, Springer Surgery Atlas Series, https://doi.org/10.1007/978-3-031-43195-1_16
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Fig. 16.1 An example of a
frozen elephant trunk device.
(a) The proximal graft section
with the 3 arch branches and
the lower body perfusion
branch. This comes attached
to a covered stent section. (b)
The device in situ
R. J. de Silva
Replacement oftheAortic Arch
plexus. A large cord of this plexus is reliably found overlying
the axillary artery and is gently retracted to give adequate
Preparation of the patient begins in the anaesthetic room,
where in addition to standard cardiac set-up, the patient must
have arterial pressure lines in both radial arteries and a suitable femoral vessel. In cases of aortic dissection, it is preferable to choose the femoral artery which is ideally not
dissected from which to transduce pressure. In addition, the
patient has a urinary catheter equipped with a temperature
probe to measure core temperature (in addition to the nasopharyngeal temperature probe), and a method of monitoring
of cerebral perfusion. For this, we currently use near infrared
spectroscopy (NIRS), taking care not to drop below baseline
readings throughout the procedure. We use cerebrospinal
uid drains in cases of chronic aortic dissections when spinal
perfusion may be vulnerable. A Swan-Ganz catheter is
placed for cardiac output monitoring which is important post
operatively.
The cardiopulmonary bypass machine is also congured
differently with two arterial return lines each with a ow
probe, so differential ows can be achieved. In these protracted procedures, we prefer to use a centrifugal pump.
Triangulation of communication between surgical, anaesthetic, and perfusion staff must be constant, clear, and concise throughout the operation.
Arterial return for the bypass machine is initially through
both axillary arteries. These are exposed in the deltopectoral
groove through a 5cm incision and subsequent division of
the pectoralis muscles (Fig.16.2). The fat pad overlying the
axillary artery is resected using a combination of cautery and
sharp dissection, taking great care not to damage the brachial
exposure. After 5000units of heparin is administered intravenously, the axillary artery is clamped using a Cooley
clamp, a linear incision is made over the clamped section of
artery and extended to 1cm in length. A 10mm diameter
vascular graft is then anastomosed to this in an end-to-side
fashion using 5/0 prolene (Fig.16.3). The graft to the right
axillary artery can be short (10cm), but to the left artery it
should be at least 20 cm in length for reasons that will
become clear in due course. We use a 3/8 inch connector join
the vascular grafts to the arterial return lines, and then proceed to median sternotomy and central venous cannulation
after full systemic heparinisation. The heart is vented through
a cannula placed in the left ventricle via the right superior
pulmonary vent, and a ‘Y’ cannula in the proximal ascending
aorta. The pericardial eld is ooded with carbon dioxide
and once on full cardiopulmonary bypass using both arterial
return lines, the patient is cooled to a nadir of 25°C on the
bladder temperature probe. During this time, if additional
cardiac procedures (e.g. valve surgery, coronary revascularization) are required, they are completed whilst cooling
down using cold blood cardioplegia for myocardial protection. If not, invariably between 27 and 30°C, the heart will
begin to brillate. At this point, a cross clamp is placed just
distal to the vent in the ascending aorta, with the handle of
the clamp pointing to the feet of the patient. The vent is then
perfused with warm blood at a physiological pressure
(between 60 and 70mmHg), as transduced through a green
hub needle placed in the aortic root. This should produce a
normal cardiac rhythm with no signs of ischaemia on the
Clavipectoral fascia
Thoracoacromial
Subclavius muscle
16 Aortic Arch andAscending Aorta Replacement
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Fig. 16.2 The axillary artery
is found deep to the
deltopectoral groove
119
Cephalic veinPectoralis minor
Pectoralis major
Fig. 16.3 10 mm vascular graft anastomosed to the axillary artery
using a 5/0 prolene suture
artery
Lateral pectoral
nerve
Pectoralis minor
Clavipectoral fascia
Axillary artery
Posterior cord
Lateral cord
Medial pectoral
nerve
Axillary vein
ECG.However in some instances this proves elusive and we
switch from warm blood perfusion to cold blood cardioplegia, which is repeated at 20min intervals.
Whilst waiting for the patient to cool, dissection of the
arch vessels is carried out. Nylon tapes are placed around the
innominate and left carotid vessels. The left subclavian
artery is usually the least accessible, and in many aortic
pathologies can be fragile. We encircle this with two silk
ligatures at its base.
With the patient core temperature at 25°C, the operating
table is moved to a steep Trendelenburg position. Before this,
an appropriate myocardial protection strategy (continuous
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warm blood perfusion or intermittent cold blood cardioplegia) must be established. The ow in the bypass machine is
dropped and clamps applied as distally as possible to the
innominate and left carotid arteries. The silk ligatures around
the proximal left subclavian artery are then tied, and the
bypass ow resumed and titrated to maintain the NIRS reading above baseline. This is usually around 10mL/kg/min,
divided equally down both arterial lines, but it is vital both
anaesthetist and perfusionist remain vigilant of the NIRS and
alter ow accordingly. The surgeon will be concentrating on
reconstructing the arch.
At this point, the lower body is ischaemic and so it is
imperative the surgeon works meticulously and efciently.
The aorta is transected at the appropriate zone. We deploy
most of our FETs in aortic zone zero or one, which means
one or both of the rst two branches of the arch are cut where
they take off from the aorta and the defect on the aorta
repaired with multiple pledgeted 4/0 prolene sutures.
A cardiotomy sucker is placed in the distal aorta to scavenge any collateral ow that will otherwise obscure the surgical eld. A pledgeted 3/0 prolene suture is placed at 2
o’clock, 6 o’clock and 10 o’clock on the distal aorta, with
pledgets lying on the outside of the native aorta. These are
hung on rubber-shod mosquito clips. A suitably sized FET is
then deployed into the aorta. In cases of aortic dissection,
this is done over a guidewire that has been introduced via the
cannulated femoral vessel, and visualised to be in the true
lumen of the thoracic aorta on TOE prior to transection of the
aorta. The 3/0 prolene sutures are used to anchor the collar of
the FET to the distal aorta, and then used to create a semicontinuous haemostatic suture line. We usually complete the
posterior part of the anastomosis rst, going from 2 to 6
o’clock. Once this suture line is completed, the ow through
the left axillary line is stopped and the graft clamped. The
left arterial return line is then separated from the graft and
connected to the lower body perfusion arm of the FET.Flow
is restarted down this arterial line, thus ending lower body
ischaemia. At 25°C, this can safely extend to 40–50min, but
invariably in our practice it is less than 30min. We aim for
lower body perfusion to produce a femoral artery pressure of
between 50 and 60mmHg.
Attention is then turned to the left carotid artery which is
anastomosed to the second branch of the FET graft using 5/0
prolene with a continuous suture line. Once the left carotid is
reperfused, patient rewarming can commence whilst the
graft anastomosed to the left axillary artery is delivered into
the mediastinum through the second intercostal space. Great
care is taken not to kink the graft. This graft is shortened to
the appropriate length and anastomosed to the third branch
of the FET graft using 4/0 prolene, then rst branch of the
FET is then anastomosed to the innominate artery using 5/0
prolene. By this point all of the arch branches are being perfused via the lower body perfusion line, and so ow into the
R. J. de Silva
Fig. 16.4 The completed arch replacement showing the arch anastomoses (a extra-anatomical left subclavian anastomosis; b left carotid
artery; c innominate artery)
right axillary artery can be stopped. The proximal graft to
aorta anastomosis is done using a single 4/0 prolene and may
require cardioplegic arrest of the heart and release of the
proximal cross-clamp to facilitate a perfect anastomosis
(Fig.16.4).
After rewarming the patient fully, weaning from bypass
can commence in routine fashion. The graft to the right axillary artery is transected short (1cm) and oversewn with a
double layer of 4/0 prolene. The axillary artery wounds are
closed taking great care not to disrupt any of the branches of
the brachial plexus.
Our technique using bilateral axillary artery cannulation
reduces the technical complexity of completing the left subclavian anastomosis in the traditional way, which is often the
most inaccessible and difcult of the anastomoses. Less
manipulation around the subclavian artery also reduces the
incidence of recurrent laryngeal nerve injury which we have
not seen in our practice for many years. Perfusion through
the left axillary line also augments bilateral cerebral and spinal perfusion that would otherwise rely on collaterals from
the right carotid and vertebral arteries.
Replacement oftheAscending Aorta
This is approached through a median sternotomy or ministernotomy down to the third intercostal space with transection of the right hemisternum to aid exposure. Central
cannulation for cardiopulmonary bypass is established, and a
vent is placed in the left ventricle through the right superior
pulmonary vein. Aortic cannulation may need to be mid arch
or of the innominate artery depending on the extent of the
aneurysm. If the right atrium is inaccessible through a ministernotomy, percutaneous cannulation of the right femoral
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