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J Thorac Cardiovasc Surg 1995;110:870-0872
© 1995 Mosby, Inc.
BRIEF COMMUNICATIONS |
Osaka and Sapporo, Japan
In patients with aneurysm of the ascending aorta associated with aortic regurgitation (AR), replacement of the vessel with a composite graft including a prosthetic valve has been widely performed.
1-3 Valve-sparing annuloaortic grafting forpatients with annuloaortic ectasia 4 associated with AR was reported by David and Feindel 5 in 1992. Although this operation is an alternative for patients who have annuloaortic ectasia and AR with normal leaflets, postoperative valvular function is still a subject of controversy. 6 We treated a patient in whom the aortic anulus became narrower after valve-sparing annuloaortic grafting, resulting in aortic stenosis and residual AR.
Case report
A 43-year-old woman had had severe chest pain on mild effort since May 1994, when she had given birth. The woman had no history of rheumatic fever, recent fever, or infection and no family history of Marfan's syndrome. She was small (142 cm in height, 46 kg in body weight), and a physical examination showed no symptoms of Marfan's syndrome. Echocardiography revealed dilatation of the base of the ascending aorta (49 mm) and grade 4/4 AR with mild prolapse of the right coronary cusp. Catheterization also showed dilatation of the ascending aorta, Sellers's grade III AR with a blood pressure of 175/75 mm Hg, and normal coronary arteries.
Median sternotomy was carried out with the use of neuroleptanalgesia with the patient in the supine position. Pump perfusion was initiated with cannulas in the ascending aorta and both cavae. After crossclamping and insertion of a venting cannula into the right superior pulmonary vein, a transverse aortic incision was made, which was then extended deep into the base of the noncoronary sinus. Cold St. Thomas' Hospital cardioplegic solution, 700 ml, was given directly into both coronary orifices. The proximal ascending aorta was dissected circumferentially down to a level immediately below the lowest portion of the aortic valve. All three sinuses of Valsalva were excised, with 5 to 7 mm of the arterial wall left attached to the aortic valve and a small button of the arterial wall remaining around the left and right coronary arteries. Thirteen interrupted horizontal mattress sutures of 4-0 Prolene polypropylene (Ethicon, Inc., Somerville, N.J.) were passed from inside to outside the left ventricular outflow tract immediately below the aortic leaflets. The leaflet height was 14 mm, and a 24 mm Hemashield graft (Meadox Medicals, Inc., Oakland, N.J.) was selected (the expected diameter of the anulus was 19 mm, which was calculated as one third longer than the leaflet. 5 The patient's anulus was 24 mm. The previously placed horizontal mattress sutures were then passed through the end of the graft. The aortic valve was placed inside the graft and all sutures were tied outside. The proximal end of the graft was sutured to surrounding tissue of the anulus with 4-0 Prolene suture for hemostasis. The arterial wall above the commissures was secured to the graft inside with pledget-supported 4-0 Prolene sutures. Next, starting at the lowest level of the right coronary cusp, a remnant of the arterial wall was sutured to the graft with a continuous 4-0 Prolene suture from inside and was continued to the left and the noncoronary cusp remnants. At this point, the anulus shrank to 15 mm because the sutures had been tied tightly around it, and additional plication of the right coronary cusp was required to relieve a severe prolapse. Competence of the aortic valve was checked by filling the graft with saline solution. The coaptation looked complete after the plication. The coronary arteries were reimplanted in the graft with a continuous 4-0 Prolene suture reinforced by felt. The upper end of the graft was then anastomosed to the ascending aorta. After release of the crossclamp, a transesophageal echocardiogram showed good coaptation without significant AR. Weaning from cardiopulmonary bypass was uneventful and the patient was transferred to the intensive care unit in good condition. Her subsequent postoperative course was uneventful, and she was discharged in good condition. Postoperative catheterization, however, revealed narrowing of the aortic anulus (15 mm) with a 24 mm Hg transvalvular pressure gradient and Sellers's grade II AR (Fig. 1).
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Composite graft replacement is a useful and reliable procedure for patients with annuloaortic ectasia associated with AR. 1-3 Its only disadvantage is the use of a prosthetic valve. AR associated with annuloaortic ectasia is caused by dilatation of an anulus or sinuses, the leaflets usually being normal. Sarsam and Yacoub, 7 in 1993, reported a procedure similar to David and Feindel's valve-sparing technique. Their technique remodels the aortic valve anulus by grafting the sinus of Valsalva for patients with AR. Although this procedure is another option for patients who have annuloaortic ectasia with normal leaflets, postoperative valvular function is still the subject of controversy 6: Can remodeling of the aortic valve anulus control the AR completely in patients with normal aortic leaflets, and how should the appropriate diameter of the anulus be determined?
Between August and October 1994, we performed valve-sparing annuloaortic grafting in four patients with annuloaortic ectasia and AR. In the third of these patients, whose case is discussed here, AR recurred as a result of shrinkage of the anulus. In the last patient, a bougie of appropriate size was positioned inside the anulus before the sutures were tied to prevent narrowing.
Another problem is whether prolapse of the right coronary cusp, which was mild before the operation, was magnified by narrowing of the anulus in this patient. Because a slight prolapse of the aortic cusp is commonly noticed on echocardiograms in patients with annuloaortic ectasia and AR, indications for valve-sparing annuloaortic grafting should be investigated in larger series.
All four patients in our series returned to New York Heart Association class I or II, and AR was well controlled in all except this one patient. Although valve-sparing annuloaortic grafting is useful for patients with annuloaortic ectasia associated with AR, more care should be taken to prevent narrowing of the aortic anulus and residual AR.
Footnotes
From the Department of Cardiovascular Surgery, National Cardiovascular Center,a Osaka, Japan, and Hokko Cardiovascular Hospital,b Sapporo, Japan. 
J THORAC CARDIOVASC SURG 1995;110:870-2
References
This article has been cited by other articles:
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  T. E. David Aortic valve haemodynamics after aortic valve-sparing operations Eur J Cardiothorac Surg, December 21, 2011; (2011) ezr119v1. [Full Text] [PDF]
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