Valve-sparing root replacement-reimplantation technique

Abstract

The first valve sparing root replacement (VSRR) was first described over thirty years ago. Reimplantation is favored at our institution to provide maximum annular support in the setting of annuloaortic ectasia. Multiple iterations for this operation have been reported. Surgical intervention varies in terms of graft sizing, the number and method of inflow suture placement, strategy for annular plication and stabilization, and finally choice of graft type. Our specific technique has evolved over the last eighteen years and the current approach is to use a larger straight graft loosely based on the original Feindel-David formula, six inflow sutures to anchor the graft, and some degree of annular plication with annular stabilization. The long-term results for both trileaflet and bicuspid valves are associated with a low reintervention rate. Herein we provide a clear outline for our specific approach to the reimplantation technique.

Keywords: Bicuspid aortic valve (BAV); aortic annuloplasty; aortic valve regurgitation; reimplantation technique; valve-sparing root replacement.

Figure 1

Sternotomy and cannulation are performed in the standard fashion. The aortotomy is performed slightly above the sinotubular junction.

Figure 2

Initially a Metzenbaum scissor pointed away from the coronary ostia is used to cut the aortic tissue vertically (A). The inferior aspect of the button is completed with a number 15 scalpel (B). 4 to 5 mm of aorta is left along the annulus. Jehle coronary catheters are used for antegrade cardioplegia (C).

Figure 3

The suction test is performed to see if the native valve can be spared. The left ventricular vent is set to high creating a vacuum and the suction device is inserted (A). Upon removal of the device, the leaflets should coapt (B). Commissural stitches are pulled vertically respecting the native valve geometry. Check the height of each cusp, ensure there is minimal calcification at the leaflet edges, and few if any fenestrations.

Figure 4

A modified version of the Feindel-David formula is used to determine graft size (A): [(avg cusp height × 4/3)+ 8–10 mm] and a cylindrical sizer is used to confirm annular diameter (B). For its flexibility, a straight graft is preferred.

Figure 5

Sub annular stitches are placed with one stitch at the nadir of each cusp, and one stitch placed below each commissure. At the right/non commissure, place the stitch outside of the annulus, in the tissue adjacent to the right atrium, to avoid damage to the conduction system in the membranous septum.

Figure 6

Tack the commissural posts. Before tying the sutures ensure the geometry allows for good coaptation of the leaflets. Use the suction test to ensure coaptation while pulling up on the commissural stitches.

Figure 7

Begin the hemostatic suture line at the nadir of each cusp and sew toward the top of each commissural post.

Figure 8

For leaflet repair of a bicuspid valve, place one stitch at the edge of the conjoined cusp where it meets the reference cusp. Ensure the leaflet heights are equal. For cusp plication, a polypropylene suture is sewn, beginning at the annular edge, working toward the free margin. This stitch is then brought back in a second layer toward the annulus. Test with the left ventricular vent on high to ensure equal cusp coaptation.

Figure 9

When sewing the coronary ostia buttons, sew the posterior suture line in individual bites. This minimizes bleeding when the cross clamp is removed.