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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3740_Библиотеки_им_академика_М_И_Перельмана
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7 Aortic Root Enlargement Techniques
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Fig. 7.2 (a) The Nicks procedure with the aortic root incised through the
centre of the non-coronary sinus across the brous aortic annulus and
extending onto the anterior mitral leaet. A bovine pericardial patch is
sutured using a 5-0 polypropylene suture starting from the apex of the
incision of the mitral valve leaet. (b) The suture is used to run on both
sides of the patch towards the aortic annulus and up the aortic root
towards the aortotomy incision to complete the aortic root reconstruction.
(c) Interrupted horizontal mattress pledgeted valve sutures are passed
from outside of the patch into the aortic aspect. The valve sutures for the
native aortic annulus are interrupted horizontal mattress sutures passed
from the ventricular to the aortic side for supra-annular valve placement.
The sutures are then passed through the cuff of the sewing ring. The valve
is tied down in the usual fashion. (d) A 4-0 polypropylene running suture
is used to close the aortotomy starting at each end of the aortotomy incision. An incision in the cranial edge of the aortotomy incision may be
required to accommodate the upper end of the pericardial patch
Manouguian-Nunez Technique
This procedure is a variation on the Nicks procedure for posterior aortic root enlargement. Here, a vertical incision in the aortic root is made across the aortic annulus at the commissure
between the left- and the non-coronary sinus across the aortic-
mitral continuity and onto the anterior mitral leaet (Fig.7.3a).
By extending this incision to within 5mm of the free margin of
the anterior mitral valve leaet and incising into the roof of the
left atrium, the aortic annulus can be enlarged by at least two
prosthetic valve size. Care is required to preserve the choral
apparatus of the anterior mitral valve leaet.
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Fig. 7.3 (a) The Manougian technique with Nunez modication. The
incision shows the Nunez technique and the classical Manougian extension to the anterior mitral valve leaet. We have also added an incision
in the roof of the left atrium to allow the widest possible aortic root
enlargement with this approach. (b) A pre-shaped double thickness of
bovine pericardial patch is sutured on either side with a 5-0 polypropylene suture as shown. (c) The two 5-0 polypropylene sutures on either
side of the double pericardial patch is passed through the edge of the
aortic root incision at the level of the aortic annulus. The posterior leaf
of the double patch is hinge towards the right of the patient and used to
repair the defect in the left atrial roof using a continuous 5-0 polypro-
The resultant defects from these incisions are closed using
a double thickness patch of bovine pericardium that bifurcates at the level of the aortic annulus (Fig.7.3b). A 5-0 poly-
pylene suture; the anterior leaf of the double patch is hinged towards the
left of the patients and used to repair the defect in the anterior mitral
leaet using another 5-0 polypropylene suture. The supra-annular valve
implantation is performed using interrupted 2-0 pledgeted Ethibond
sutures in the standard fashion. The sutures are placed from outside the
patch into the aortic aspect and passed through the sewing cuff of the
prosthesis. (d) The valve is tied in place and the double patch can be
seen “bifurcating” at the level of the aortic annulus with one leaf patching the left atrial roof and the other leaf patching the anterior mitral
leaet
propylene stay suture is used to approximate each side of the
hinge point of the double thickness patch to each cut edge of
the aortic annulus. The inner leaf of the patch is hinged
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39
towards the left ventricular outow tract to repair the defect
in the anterior mitral valve leaet using a fresh 5-0 polypropylene suture starting at the apex of the mitral leaet incision
and running towards the aortic annulus on each side of the
patch (Fig.7.3c). The outer leaf of the double patch is hinged
onto the roof of the left atrium. A separate 5-0 polypropylene
suture is used starting at the apex of the left atrial incision
and running towards the aortic annulus on each side of the
patch and tied against the corresponding suture from the
mitral leaet repair (Fig.7.3d). Finally, the two 5-0 polypropylene stay sutures at either side of the hinge point of the
patch is run up each side of the double patch and the aortic
root. The enlarged aortic root is sized, an aortic valve
prosthesis is inserted, and the aortotomy is closed as
described in the previous section.
It cannot be emphasised enough that all the suture lines
must be haemostatic, especially those between the mitral
leaet and the pericardial patch. An additional 5–7min doing
this can avoid having to redo the whole procedure!
Konno-Rastan Technique
This is an anterior aortic root enlargement or an aortoventriculoplasty that is most commonly performed in congenital
cardiac surgical units and is rarely deployed in the adult pop-
ulation. It is included briey in this chapter for the sake of
completeness.
The aortic root is mobilised by separating the right coronary sinus and the pulmonary trunk down to the level of the
aortic annulus. A vertical aortotomy is performed to the left
of the right coronary ostium from the level of the sinotubular
junction and into the right coronary sinus (Fig. 7.4a). The
incision is then extended onto the anterior surface of the right
ventricular outow track and into the interventricular septum
as far as required for the desired aortic root enlargement
(Fig. 7.4a). The danger is that the deeper the incision the
higher the risk of injury to the rst septal branch of the left
anterior descending artery.
Next a large bifurcating double layer of diamondshaped bovine pericardial patch is used to reconstruct the
left ventricular outow tract using 4-0 polypropylene running suture (Fig.7.4b) starting at the apex of the incision
in the interventricular septum. When these sutures reach a
level of 5mm above the native aortic valve annulus, the
enlarged aortic annulus is sized, the valve sutures are
inserted, and the aortic valve prosthesis is implanted
(Fig.7.4c). The inner leaf of the double layer of pericardial
patch is used to repair the defect in the aortic root. The
outer leaf of the double layer of pericardial patch is used to
repair the defect in the right ventricular outow track
(Fig.7.4d).
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Cardiomyotomy
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R. Q. Attia et al.
a
Aortotomy
Pulmonary
valve
Right
ventricular
cardiomyotomy
Right
coronary a.
Aorta
Pulmonary
outflow tract
through right
coronary cusp
SVC
Fig. 7.4 (a) Konno-Rastan aortoventriculoplasty. The aortic root is
enlarged with an incision through the right coronary portion of the aortic annulus, near the commissure, between the right and left coronary
cusps. The incision is deepened into the interventricular septum, and a
matching incision is made on the right ventricular free wall to enlarge
the right ventricular outow tract. (b) A diamond-shaped double patch
of bovine pericardium is placed deep into the interventricular septal
incision. Continuous sutures are used to attach the double patch to the
ventricular muscle running up to the level of the aortic annulus. (c)
Pulmona
trunk
RVOT
Ventr
septum
Pledgeted 2-0 Ethibond sutures are used to secure the prosthetic valve
to the aortic annulus and through the double pericardial patch from the
RV to the LV side. The sutures are then passed through the sewing ring
of the prosthetic valve. (d) The outer leaf of the double pericardial patch
is folded outwards to repair the right ventricular free wall defect, and
continuous sutures are used to attach the patch to the muscle. The inner
leaf of the double pericardial patch is used to close the left ventricular
outow tract using the continuous suture technique
b
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Outside patch with pledgeted annular
sutures placed through inside patch
c
Aortic valve
replaced
d
Top area of inner
patch to be used
for closing aortic
defect
Right ventricular
defect closed with
RVOT outer patch
coronary
Fig. 7.4 (continued)
Aorta
Right
artery
Pulmonary
trunk
Aortic part
of inside patch
Outside patch
over RVOT
defect
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R. Q. Attia et al.
Y Technique
There is a recent addition to the literature of a Y incision at
the aortomitral curtain and a rectangular patch enlargement
of the aortic root described by Yang, apparently allowing
three to four size increase in the aortic prosthesis without
violating the mitral valve [5]. However, since there is currently limited long-term follow-up on this techniques, readers are referred to the original publication for further
information.
Conclusions
A physically active patient with a disproportionately small
aortic annulus is at risk of patient prosthesis mismatch following standard aortic valve replacement which is associated
with inferior early and late outcomes in some studies. The
various procedures described for aortic root enlargement are
effective in the hands of an experienced surgeon [6].
However, good myocardial protection and meticulous care
must be taken during surgery to ensure safe and reproducible
results.
References
1. Nicks R, Cartmill T, Bernstein L.Hypoplasia of the aortic root. The
problem of aortic valve replacement. Thorax. 1970;25:339–46.
2. Manouguian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior
mitral leaet: new operative technique. J Thorac Cardiovasc Surg.
1979;78:402–12.
3. Nuñez L, Gil Aguado M, Pinto AG, Larrea JL.Enlargement of the
aortic annulus by resecting the commissure between the left and
noncoronary cusps. Tex Heart Inst J. 1983;10:301–3.
4. Konno S, etal. A new method for prosthetic vale replacement in
congenital aortic stenosis associated with hypoplasia of the aortic
valve ring. J Thorac Cardiovasc Surg. 1975;70:909–9917.
5. Yang B.A novel simple technique to enlarge the aortic annulus by
two valve sizes. J Thorac Cardiovasc Surg. 2021;5:13–6.
6. Dhareshwar J, Sundt T III, Dearani J, Schaff H, Cook D, Orszulak
T.Aortic root enlargement: what are the operative risks? J Thorac
Cardiovasc Surg. 2007;134:916–24.
Valve Sparing Aortic Root Replacement
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RizwanQ.Attia andRaviJ.de Silva
8
Valve preservation during aortic root surgery has evolved
over the last two decades with efforts from surgeons such as
Sir Magdi Yacoub and Tirone David. Aortic root replacement
entails complete excision and replacement of the aortic
valve, all aortic sinuses, and reimplantation of the coronaries
into the prosthetic aortic root. This is the Bentall operation,
rst described in 1968. If the valve is preserved, then it is
referred to as Valve Sparing Aortic Root Replacement
(VSARR). The procedure has been simplied and standardised by surgeons such as Duke Cameron with exceptionally robust outcomes [1–3]. This technique is categorised
into aortic root remodelling (aortic graft sits on top of the
valve complex) or reimplantation (valve complex is located
within the aortic graft).
The remodelling operation creates neo-sinuses which
have a theoretical advantage to leaet integrity and ow
dynamics. This procedure does not stabilise the aortic
annulus (Fig.8.1). Modications to the remodelling operation buttress the annulus using sutures or prosthetic strips
which have yielded non-uniform outcomes. Custom prostheses allow combined remodelling of sinuses and annular
stability of reimplantation. One such prosthesis is the
Valsalva graft which is a bovine gelatine impregnated
Dacron graft which can be used in remodelling or reimplantation (Fig.8.2). It combines a collar with horizontal
pleats, a vertically pleated skirt section that makes the sinus
segment, and horizontally pleated tubular segment which
can be used to replace more of the ascending aorta as
required. The graft comes in 24–34mm sizes allowing use
in most adolescent and adult aortic root reconstructions,
our practice at Royal Papworth is to use this graft for the
implantation technique of VSARR.
R. Q. Attia
Department of Cardiothoracic Surgery and Transplantation, Royal
Papworth Hospital, Cambridge, UK
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_8
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b
Fig. 8.1 Aortic root remodelling procedure (Yacoub technique) for a
valve sparing aortic root reconstruction. (a) The native diseased root is
excised, and the native commissural posts with leaets attached are
retained. (b) Unlike the reimplantation technique, this technique reconstructs the aorta with a graft using three ‘tongue-like’ projections which
d
replace the native aortic sinuses. The graft is then sutured into the
patients’ remnant aortic sinuses next to the annulus. (c) The coronary
artery button as reattached and (d) the nal result retains the native
valve but does not stabilise the annulus as the aortic graft remains outside the native annulus
Surgical Technique
Median sternotomy is carried out, and after creation of a
pericardial well, the heart is prepared for cannulation and
placement onto cardiopulmonary bypass. Aortic arch cannulation is preferred with an appropriately sized aortic and dual
stage venous cannula into the right atrium. Cardiopulmonary
bypass is commenced, and the patient is cooled to 32°C.One
litre of cold blood cardioplegia is delivered into the aortic
root using a DLP cannula into the ascending aorta after
placement of an aortic cross-clamp. In cases of severe aortic
valve incompetence, induction and maintenance doses of
cardioplegia are delivered through a combination of direct
coronary ostial and retrograde cardioplegia. Repeated intermittent dosing of the cardioplegia is performed every 20min
throughout the case. Topical cold saline is also used for myocardial protection, and a vent is placed in the left ventricle
via the right superior pulmonary vein.
The aorta is transected above the sinotubular junction
(STJ), and if the ascending aorta is aneurysmal, this is
excised, thus improving exposure to the root. The coronary
buttons are fashioned and retracted away from the root using
a pledgeted 4/0 prolene stay suture (Fig.8.3). Stay sutures
with 5/0 prolenes are placed on top of each of the three commissures, and the aortic sinus tissue is resected leaving a
5mm wide circumferential rim which is used to construct
the internal suture line. Aortic root dissection is carried out
using a combination of electrocautery and sharp dissection
Fig. 8.2 Gelweave™ Valsalva graft (Terumo Aortic)
to separate the right and main pulmonary arteries from the
Right
Left
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coronary button
Fig. 8.3 Dissection of the aortic root and fashioning coronary buttons
Dissection around exterior aortic annulus
Fig. 8.4 Deep circumferential dissection of the aortic root from the
pulmonary artery, left atrium around the LVOT
coronary button
aortic root (Fig. 8.4). Next attention is turned to the noncoronary sinus, and the atrial and epicardial fat is dissected
away from the annulus and the left-right coronary aortic leaflets are separated from the pulmonary artery as low as possible. A circumferential deep dissection of tissue is required
below the annulus of the aortic valve (Fig.8.4). This may be
particularly hazardous below the right coronary cusp, and
inadvertent breach of the right ventricle can be difcult to
repair. We prefer sharp dissection in this area in combination
with a surgical peanut to peal the right ventricle away from
the aortic annulus.
45
We use one of two techniques to choose the appropriate
size for the Valsalva graft. One technique employs a St Judes
Medical Valve Sizer with traction on the commissural stay
sutures to assess the size of the STJ diameter. The STJ diameter is usually preserved or slightly reduced to maintain aortic leaet apposition and valve competence. Once the ideal
diameter is picked, 2–3mm is added to account for aortic
wall thickness as the Valsalva graft sits outside the aortic
valve root complex. This means most adult females would
receive a 30-mm and adult men a 32-mm graft. The other
technique of graft sizing measures the interleaet triangle
height, which is most easily accessed at the left/non commissure. We nd these two techniques corroborate accurately.
The base of the graft is cut to three rings and the distal end
to about ve to seven rings. A long tubular graft makes suture
placement difcult and typically this length sufces to
replacement of most ascending aortae. Three black marks
are already placed onto the graft which align with the commissures. The authors use a surgical marker to make three
further longitudinal markers that subdivide the graft into the
three sinus segments. This marks sites of the coronary artery
implants, the middle and nadir of each subannular suture. A
small nick is made into the graft at the bottom along the
already placed black lines to allow the graft to sink down into
the left-right and right-non-coronary commissures. This
allow easy low seating of the graft which is very important
specially in cases where deep dissection of the root is difcult without entering the right ventricle. Usually, the nick
needs a single interrupted 4/0 prolene suture to repair any
gaps once tied down.
Three horizontal mattress sutures are placed within the
left ventricular outow tract below the nadir of each leaet
and out through the aortic root using 3/0 prolene with rectangular pledgets (Fig.8.5). The three sutures from the commissures are drawn up through the graft, and the subannular
sutures are placed through the base of the graft where the
previously placed surgical marks were made, denoting the
midpoint of each sinus. The graft is now lowered into position, and the subannular sutures are tied (Fig.8.6).
The aortic root complex is orientated within the graft
(Fig. 8.7). In a symmetrical trileaet aortic valve, the
commissures should correspond to the black lines on the
graft. Asymmetrical and bicuspid valves need further expert
judgement which can only be gained with experience and is
beyond the remit of this chapter. The haemostatic suture line
is now constructed from the pledgeted 5/0 prolene horizontal
mattress suture placed at the tip of each commissure. If the
correct graft size is chosen, this suture will sit just below
where the skirt of the graft transitions to the tubular section.
Both limbs of the suture are taken through the graft and tied
together on the outside keeping both needles attached. One
needle is hung on a rubbershod whilst the other needle is
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Fig. 8.5 Three horizontal mattress 2/0 Ethibond sutures placed from
within the LVOT and out through the aortic root below the nadir of
aortic valve leaet
Fig. 8.6 The valve commissural sutures are placed through the graft
which is lowered in place with the anchoring sutures placed within the
aortic root
R. Q. Attia and R. J. de Silva
Fig. 8.7 The three anchoring subannular sutures are tied, and the aortic
valve complex is orientated. Next step is assessment of the commissural
sutures which are tied and the haemostatic suture line is begun within
the graft valve complex
passed through the graft and the 5mm circumferential aortic
tissue. The internal suture line is then constructed with this
5/0 prolene suture either as a running ‘in and out’ suture line
(Fig.8.7) or as an ‘over and over’ technique. It is crucial to
incorporate both graft and aortic tissue with every bite, and
to instruct your assistant to maintain tension on the suture
line throughout. As you approach the next commissure, it
helps to secure this commissure to the graft as previously
described, and then tie the suture used to construct the long
internal suture line to one limb of the commissural suture on
the outside of the graft. Thus, eventually the internal suture
line is completed (Fig. 8.7). Two points to note are to
straighten the graft and the tissues to avoid any folds and take
care not to injure the leaets. Once all suture lines are completed, we inspect the graft and perform static testing with
saline to assess leaet apposition and test valve competence.
This is done with the left ventricular vent on to create negative suction on the aortic valve, so any incompetence is exaggerated. By passing the wall sucker through the aortic valve
and then slowly withdrawing, it also gives a useful indication
of leaet coaptation length, which should ideally be more
than 5mm.
Valve repair can now be carried out if required. Any pro-
lapsing areas can be treated with a 5/0 prolene suture to fold
the midportion of the free leaet. Any small fenestrations are
also similarly repairable, although if these are covered by the
coapting leaets, it is preferable to leave well alone.
Next attention is turned to attaching the coronary buttons
starting with the left which is usually in alignment with the
midportion of the left coronary sinus (Fig.8.8). A burner is
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