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J Thorac Cardiovasc Surg 2004;127:264-266
© 2004 The American Association for Thoracic Surgery

Brief communication

Management of aortic insufficiency in patients with left ventricular assist devices: A simple coaptation stitch method (Park's stitch)

^a Department of Surgery, University of Minnesota, Minneapolis, Minn, USA
^b Department of Medicine, University of Minnesota, Minneapolis, Minn, USA

Received for publication January 28, 2003; accepted for publication June 18, 2003.

^* Address for reprints: Soon J. Park, MD, Associate Professor, Director Cardiac Assistance Program, St Jude Medical Chair in Biomedical Engineering, University of Minnesota, Department of Surgery, 420 Delaware Street SE, MMC 207, Minneapolis, MN 55455, USA
parkx021{at}umn.edu

Left ventricular assist device (LVAD) implantation increases survival and quality of life for patients with advanced heart failure.¹ Because of device design, competence of the native aortic valve is critically important. Even trivial aortic insufficiency could worsen with time,² and the regurgitant flow could make the device ineffective for hemodynamic support.

Managing native aortic valve insufficiency at the time of LVAD implantation has been challenging. Various procedures to prevent aortic insufficiency have been anecdotally reported (eg, aortic valve replacement with a bioprosthetic valve or with a polytetrafluoroethylene patch, or primary closure of the aortic valve opening).^3-5 Such procedures have been performed successfully, but they could make surgery more complicated. We describe a simple coaptation stitch method of dealing with central aortic insufficiency at the time of LVAD implantation in 2 patients.

Case summaries

Patient 1
A 61-year-old man with a long-standing history of ischemic cardiomyopathy had a myocardial infarction and was in cardiogenic shock. The LVAD (HeartMate-XVE, Thoratec Corporation, Pleasanton, Calif) was implanted uneventfully. Because of patent venous grafts, anastomosis of the outflow graft to the aorta was completed under aortic crossclamping. Through the aortotomy incision between two proximal vein grafts we were able to inspect the native aortic valve for myxomatous changes. We then placed a coaptation stitch at the central portion of the cusps to ensure aortic valvular competence. The patient was supported with the LVAD as an outpatient for about 6 months, after which he underwent heart transplantation. His excised heart showed that the coaptation stitch was in good condition, without any commissural or leaflet problems.

View larger version (98K): [in this window] [in a new window]   Figure 1. A, A transesophageal echocardiogram demonstrates a moderate aortic insufficiency jet. B, No aortic insufficiency is noted following placement of Park’s coaptation stitch.

Recommended procedure
Candidates for LVAD implantation are evaluated by echocardiography to assess native aortic valve insufficiency. Those with pronounced aortic valve incompetence as a result of structural problems of the valve may need to undergo aortic valve replacement or surgical closure of the aortic valve leaflets. Mild to moderate aortic insufficiency, however, can be corrected with a simple coaptation stitch placed at the central portion of the three aortic cusps.

First, a routine median incision is made for LVAD implantation. The ascending aorta is cannulated centrally with an aortic cannula. The superior and inferior venae cavae are cannulated through the right atrial wall. Cardiopulmonary bypass is initiated. The native aortic valve is examined with transesophageal echocardiography, which should estimate the degree of aortic insufficiency to be expected on LVAD support. Any degree of insufficiency (more than trace) should be corrected with a coaptation stitch.

The aortic crossclamp is applied to arrest the heart with antegrade cardioplegia infusion. If the aortic insufficiency impairs antegrade cardioplegia infusion, a retrograde catheter may be used instead. Then a lateral aortotomy incision is made, long enough to complete the anastomosis between the outflow graft and the aorta. An aortic root retractor is placed, and the native aortic valve is inspected through the incision. The cusps of the native aortic valve are carefully examined to make sure that no other structural problems could be causing the aortic insufficiency. If the central aortic insufficiency is due to poor coaptation of the myxomatous aortic valve, then a simple coaptation stitch at the center will easily mend this problem. Pledget-supported 4-0 Prolene sutures (Ethicon, Inc, Somerville, NJ) are applied to approximate the fibrous nodules of Arantius (Figure 2).

View larger version (23K): [in this window] [in a new window]   Figure 2. Pledgeted 4-0 Prolene sutures are applied to approximate the fibrous nodules of Arantius to create a coaptation stitch.

Discussion
A simple coaptation stitch is useful for managing mild to moderate aortic insufficiency in patients undergoing LVAD implantation. It effectively eliminates native aortic valve insufficiency. Use of this stitch in otherwise competent aortic valves at the time of LVAD implantation for long-term support may reduce the incidence of LVAD-related aortic insufficiency with time as well.

References

1. Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, et al. Long-term mechanical left ventricular assistance for end-stage heart failure. N Engl J Med. 2001;345:1435–1443[Medline]
   
2. Samuels LE, Thomas MP, Holmes EC, Narula J, Fitzpatrick J, Wood D, et al. Insufficiency of the native aortic valve and left ventricular assist system inflow valve after support with an implantable left ventricular assist system: signs, symptoms and concerns. J Thorac Cardiovasc Surg. 2001;122:380–381[Free Full Text]
   
3. McCarthy PM, Smedira NO, Vargo RL, Goormastic M, Hobbs RE, Starling RC, et al. One hundred patients with the HeartMate left ventricular assist device: evolving concepts and technology. J Thorac Cardiovasc Surg. 1998;115:904–912[Abstract/Free Full Text]
   
4. Savage EB, d'Amato TA, Magovern JA. Aortic valve patch closure: an alternative to replacement with HeartMate LVAS insertion. Eur J Cardiothorac Surg. 1999;16:359–361[Abstract/Free Full Text]
   
5. Naka Y, Edwards NM, Oz MC. Novel technique to repair type A acute aortic dissection in patients with a left ventricular assist device. Ann Thorac Surg. 2001;72:1403–1404[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Soon J. Park Kenneth K. Liao Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Park, S. J. Articles by Miller, L. W. Search for Related Content PubMed PubMed Citation Articles by Park, S. J. Articles by Miller, L. W. Related Collections Mechanical Circulatory Assistance