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Cusp Nadir Relocation by Root Remodeling in Unicuspid Aortic Valve Repair
Journal Pre-proof Cusp Nadir Relocation by Root Remodeling in Unicuspid Aortic Valve Repair Shunsuke Matsushima, MD, Alexander Heß, MD, Maximilian Glenske, Klaus Hoffmann, MD, Alexander Raddatz, MD, Hans-Joachim Schäfers, MD, PhD PII:
S0003-4975(19)31205-6
DOI:
https://doi.org/10.1016/j.athoracsur.2019.06.085
Reference:
ATS 32909
To appear in:
The Annals of Thoracic Surgery
Received Date: 21 January 2019 Revised Date:
13 June 2019
Accepted Date: 21 June 2019
Please cite this article as: Matsushima S, Heß A, Glenske M, Hoffmann K, Raddatz A, Schäfers HJ, Cusp Nadir Relocation by Root Remodeling in Unicuspid Aortic Valve Repair, The Annals of Thoracic Surgery (2019), doi: https://doi.org/10.1016/j.athoracsur.2019.06.085. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 by The Society of Thoracic Surgeons
1
Cusp Nadir Relocation by Root Remodeling in Unicuspid Aortic Valve Repair Running Head: REMODELING OF THE UNICUSPID AORTIC VALVE
Shunsuke Matsushima1, MD, Alexander Heß1, MD, Maximilian Glenske1, Klaus Hoffmann2, MD, Alexander Raddatz2, MD, and Hans-Joachim Schäfers1, MD, PhD
1. Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany 2. Department of Anesthesiology, Saarland University Medical Center, Homburg/Saar, Germany
Corresponding Author: Hans-Joachim Schäfers, MD, PhD Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany E-mail: [email protected]
2
Abstract We describe a root remodeling technique for the unicuspid and unicommissural aortic valve with a moderately hypoplastic anterior commissure, which achieves symmetric bicuspidization without patch insertion to cusps. Partial cusp fusion of the anterior commissure is divided, and two symmetric tongues of a Dacron graft are sutured to each center of cusp insertion lines. The cusp nadirs are relocated posteriorly, and the bicuspidized valve has two sufficiently high commissures from a new angulated virtual basal ring. To optimize valve configuration, annuloplasty and prolapse correction according to effective height concept are added. This technique is a promising option in selected patients.
3
The unicuspid and unicommissural aortic valve (UAV) has one fully developed commissure of normal height, typically the normal posterior commissure (left/noncoronary), and the other lower commissures with variable cusp fusion (Fig 1A) [1]. This congenital morphology is rare but frequently requires surgical intervention in young adults to treat either aortic valve dysfunction or aortic aneurysm [2]. In order to repair the UAV, we have proposed symmetric bicuspidization by detaching the rudimentary anterior (right/noncoronary) commissure and creating a new commissure of normal height with adding two triangular patches [3-5]. In selected UAVs, however, symmetric bicuspidization can be designed without additional cusp tissue. This report describes a root remodeling technique for the UAV with a moderately hypoplastic anterior commissure, in which the cusp nadirs are relocated posteriorly compared to their original positions and two sufficiently high commissures from a new angulated virtual basal ring are created.
Technique The geometry of the aortic root and cusp is assessed by transesophageal echocardiography. Images on short-axis examination show common landmarks for the UAV, i.e. the eccentric valvular orifice, rounded leaflet free edge on the side opposite the commissural attachment, and posteriorly positioned single commissural attachment (Fig 2A-B, Video) [2]. A diameter of the sinus of Valsalva exceeding 42 mm triggers root remodeling in our practice. After aortic cross-clamping, the ascending aorta is incised longitudinally and transected horizontally 10 mm above the normal posterior commissure. The aortic valve is inspected for possible repair. UAV repair is pursued if geometric heights of the anatomical left coronary and noncoronary cusps are 20 mm or more [4, 5]. Moreover, each commissural height is determined. If the height difference between the posterior and hypoplastic anterior commissures is less than 10 mm and the tissue of anterior cusp fusion is not calcified, this technique is feasible. The sinus wall is excised, and the two coronary buttons are mobilized. Stay sutures, placed above the anterior and posterior commissures, are adjusted to make the cusp apposition symmetric and suppose new cusp nadirs relocated posteriorly on the cusp insertion lines (Fig 3A). The anterior cusp fusion is divided. Two symmetric tongues are created in a Dacron graft chosen according to body
4
surface area (BSA) of the patient (<1.8 m2: 24 mm, 1.8-2.2 m2: 26 mm, >2.2 m2: 28 mm), and sutured to cusp insertion lines; each center of these tongues corresponds to each new cusp nadir (Fig 1B, Fig 3B). Hereby, the bicuspidized valve obtains two commissures located at 180 degrees orientation and of same height from a new and angulated basal plane (Fig 1C, Fig 3C). The valve configuration is further optimized in the standard manner as we apply in root remodeling for the bicuspid aortic valve (Fig 3D) [6]. In patients with an annular diameter exceeding 25 mm, an external suture annuloplasty is performed with an expanded polytetrafluoroethylene suture, which is tied around a Hegar sizer (BSA<1.8 m2: 23 mm, BSA≥1.8 m2: 25 mm). Subsequently, the effective height of cusps is measured [3-6]. Any effective height < 9 mm is considered as prolapse and corrected with central plication sutures on the cusps until an effective height of 9 to 10 mm is achieved. Both coronary buttons are implanted into suitable positions of the Dacron graft. Symmetry and function of the bicuspidized valve are assessed by transesophageal echocardiography after aortic declamping (Fig 2C-D, Video). Between 2011 and 2018, this procedure was performed in 4 patients with an UAV at the age of 25 - 58 years. All patients required an external suture annuloplasty and cusp plications. The extracorporeal circulation time was 71 - 89 minutes, and the aortic cross-clamp time was 58 - 73 minutes. All patients are alive, require no reoperations, and have no or only mild aortic regurgitation during the follow-up period of 0.3 – 6.9 years.
Comment Durable repair of the UAV is an attractive option for young patients to avoid negative consequences of valve replacement with a mechanical prosthesis. Our approach of symmetric bicuspidization by creating an opposed commissure with patch insertion provides satisfactory outcomes [3-5]. Nevertheless, we believe that use of a patch for cusp repair should be avoided if possible since its use is a known risk factor for valve failure [6]. If its morphology and geometry permit, this cusp nadir relocation by root remodeling can be a valid alternative for UAV repair. The decision whether this technique is feasible is made depending on the degree of anterior commissural hypoplasia. The height of the anterior commissure is estimated by comparing it to the
5
height of the posterior commissure and the level of the right coronary ostium [3]. A normal commissural height is in the range of 18 - 25 mm [7]. If the height of the anterior commissure is at least 15 mm, this technique can be applied. By relocating the cusp nadirs toward the posterior commissure, the axis of the new virtual basal ring inclines anteriorly, and a symmetric frame is provided for the cusps. Both postoperative commissural heights will be 20 to 25 mm and seems to be sufficient for adequate valve configuration. Such a moderately hypoplastic anterior commissure is commonly associated with partial fusion between the right coronary and noncoronary cusps, which facilitates creation of the new commissure with adequate cusp opening. The general tools of aortic valve repair will have to be applied as needed, e.g. external suture annuloplasty and prolapse correction according to effective height concept [5, 6]. Our current experience is still limited, but nonetheless, this procedure is a promising approach in selected patients.
6
References 1.
Anderson RH. Understanding the structure of the unicuspid and unicommissural aortic valve. J Heart Valve Dis 2003;12: 670–3.
2.
Novaro GM, Mishra M, Griffin BP. Incidence and echocar diographic features of congenital unicuspid aortic valve in an adult population. J Heart Valve Dis 2003;12:674–8.
3.
Schäfers HJ, Aicher D, Riodionycheva S, et al. Bicuspidization of the unicuspid aortic valve: a new reconstructive approach. Ann Thorac Surg 2008;85:2012–8.
4.
Aicher D, Bewarder M, Kindermann M, Abdul-Khalique H, Schäfers HJ. Aortic valve function after bicuspidization of the unicuspid aortic valve. Ann Thorac Surg 2013;95:1545–50.
5.
Franciulli M, Aicher D, Rädle-Hurst T, Takahashi H, Rodionycheva S, Schäfers HJ. Root remodeling and aortic valve repair for unicuspid aortic valve. Ann Thorac Surg 2014;98:823–9.
6.
Schneider U, Feldner SK, Hofmann C, et al. Two decades of experience with root remodeling and valve repair for bicuspid aortic valves. J Thorac Cardiovasc Surg 2017;153:S65–71.
7.
De Kerchove L, Momeni M, Aphram G, et al. Free margin length and coaptation surface area in normal tricuspid aortic valve: an anatomical study. Eur J Cardiothorac Surg 2018;53:1040–8.
7
Figure Legends Fig 1. Schematic diagrams of cusp nadir relocation. (A) Structure of the unicuspid aortic valve is inspected. The anterior cusp fusion is divided to extend cusp free margin (arrow). (B) Two symmetric tongues of a Dacron graft are sutured to each new cusp nadir (circle) relocated posteriorly (arrow). (C) The aortic valve obtains two symmetric commissures of sufficient height from a new angulated basal plane. Fig 2. Short-axis views of transesophageal echocardiography before procedure (A; systole, B: diastole) and after procedure (C: systole, D: diastole). Fig 3. Intraoperative photographs. (A) Exposure and inspection of the unicuspid aortic valve. (B) Two symmetric tongues of a Dacron graft are sutured to each new cusp nadir. (C) Two symmetric commissures of sufficient height are created. (D) The general tools for bicuspid aortic valve repair are applied to optimize the valve configuration.
S0003-4975(19)31205-6
DOI:
https://doi.org/10.1016/j.athoracsur.2019.06.085
Reference:
ATS 32909
To appear in:
The Annals of Thoracic Surgery
Received Date: 21 January 2019 Revised Date:
13 June 2019
Accepted Date: 21 June 2019
Please cite this article as: Matsushima S, Heß A, Glenske M, Hoffmann K, Raddatz A, Schäfers HJ, Cusp Nadir Relocation by Root Remodeling in Unicuspid Aortic Valve Repair, The Annals of Thoracic Surgery (2019), doi: https://doi.org/10.1016/j.athoracsur.2019.06.085. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 by The Society of Thoracic Surgeons
1
Cusp Nadir Relocation by Root Remodeling in Unicuspid Aortic Valve Repair Running Head: REMODELING OF THE UNICUSPID AORTIC VALVE
Shunsuke Matsushima1, MD, Alexander Heß1, MD, Maximilian Glenske1, Klaus Hoffmann2, MD, Alexander Raddatz2, MD, and Hans-Joachim Schäfers1, MD, PhD
1. Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany 2. Department of Anesthesiology, Saarland University Medical Center, Homburg/Saar, Germany
Corresponding Author: Hans-Joachim Schäfers, MD, PhD Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany E-mail: [email protected]
2
Abstract We describe a root remodeling technique for the unicuspid and unicommissural aortic valve with a moderately hypoplastic anterior commissure, which achieves symmetric bicuspidization without patch insertion to cusps. Partial cusp fusion of the anterior commissure is divided, and two symmetric tongues of a Dacron graft are sutured to each center of cusp insertion lines. The cusp nadirs are relocated posteriorly, and the bicuspidized valve has two sufficiently high commissures from a new angulated virtual basal ring. To optimize valve configuration, annuloplasty and prolapse correction according to effective height concept are added. This technique is a promising option in selected patients.
3
The unicuspid and unicommissural aortic valve (UAV) has one fully developed commissure of normal height, typically the normal posterior commissure (left/noncoronary), and the other lower commissures with variable cusp fusion (Fig 1A) [1]. This congenital morphology is rare but frequently requires surgical intervention in young adults to treat either aortic valve dysfunction or aortic aneurysm [2]. In order to repair the UAV, we have proposed symmetric bicuspidization by detaching the rudimentary anterior (right/noncoronary) commissure and creating a new commissure of normal height with adding two triangular patches [3-5]. In selected UAVs, however, symmetric bicuspidization can be designed without additional cusp tissue. This report describes a root remodeling technique for the UAV with a moderately hypoplastic anterior commissure, in which the cusp nadirs are relocated posteriorly compared to their original positions and two sufficiently high commissures from a new angulated virtual basal ring are created.
Technique The geometry of the aortic root and cusp is assessed by transesophageal echocardiography. Images on short-axis examination show common landmarks for the UAV, i.e. the eccentric valvular orifice, rounded leaflet free edge on the side opposite the commissural attachment, and posteriorly positioned single commissural attachment (Fig 2A-B, Video) [2]. A diameter of the sinus of Valsalva exceeding 42 mm triggers root remodeling in our practice. After aortic cross-clamping, the ascending aorta is incised longitudinally and transected horizontally 10 mm above the normal posterior commissure. The aortic valve is inspected for possible repair. UAV repair is pursued if geometric heights of the anatomical left coronary and noncoronary cusps are 20 mm or more [4, 5]. Moreover, each commissural height is determined. If the height difference between the posterior and hypoplastic anterior commissures is less than 10 mm and the tissue of anterior cusp fusion is not calcified, this technique is feasible. The sinus wall is excised, and the two coronary buttons are mobilized. Stay sutures, placed above the anterior and posterior commissures, are adjusted to make the cusp apposition symmetric and suppose new cusp nadirs relocated posteriorly on the cusp insertion lines (Fig 3A). The anterior cusp fusion is divided. Two symmetric tongues are created in a Dacron graft chosen according to body
4
surface area (BSA) of the patient (<1.8 m2: 24 mm, 1.8-2.2 m2: 26 mm, >2.2 m2: 28 mm), and sutured to cusp insertion lines; each center of these tongues corresponds to each new cusp nadir (Fig 1B, Fig 3B). Hereby, the bicuspidized valve obtains two commissures located at 180 degrees orientation and of same height from a new and angulated basal plane (Fig 1C, Fig 3C). The valve configuration is further optimized in the standard manner as we apply in root remodeling for the bicuspid aortic valve (Fig 3D) [6]. In patients with an annular diameter exceeding 25 mm, an external suture annuloplasty is performed with an expanded polytetrafluoroethylene suture, which is tied around a Hegar sizer (BSA<1.8 m2: 23 mm, BSA≥1.8 m2: 25 mm). Subsequently, the effective height of cusps is measured [3-6]. Any effective height < 9 mm is considered as prolapse and corrected with central plication sutures on the cusps until an effective height of 9 to 10 mm is achieved. Both coronary buttons are implanted into suitable positions of the Dacron graft. Symmetry and function of the bicuspidized valve are assessed by transesophageal echocardiography after aortic declamping (Fig 2C-D, Video). Between 2011 and 2018, this procedure was performed in 4 patients with an UAV at the age of 25 - 58 years. All patients required an external suture annuloplasty and cusp plications. The extracorporeal circulation time was 71 - 89 minutes, and the aortic cross-clamp time was 58 - 73 minutes. All patients are alive, require no reoperations, and have no or only mild aortic regurgitation during the follow-up period of 0.3 – 6.9 years.
Comment Durable repair of the UAV is an attractive option for young patients to avoid negative consequences of valve replacement with a mechanical prosthesis. Our approach of symmetric bicuspidization by creating an opposed commissure with patch insertion provides satisfactory outcomes [3-5]. Nevertheless, we believe that use of a patch for cusp repair should be avoided if possible since its use is a known risk factor for valve failure [6]. If its morphology and geometry permit, this cusp nadir relocation by root remodeling can be a valid alternative for UAV repair. The decision whether this technique is feasible is made depending on the degree of anterior commissural hypoplasia. The height of the anterior commissure is estimated by comparing it to the
5
height of the posterior commissure and the level of the right coronary ostium [3]. A normal commissural height is in the range of 18 - 25 mm [7]. If the height of the anterior commissure is at least 15 mm, this technique can be applied. By relocating the cusp nadirs toward the posterior commissure, the axis of the new virtual basal ring inclines anteriorly, and a symmetric frame is provided for the cusps. Both postoperative commissural heights will be 20 to 25 mm and seems to be sufficient for adequate valve configuration. Such a moderately hypoplastic anterior commissure is commonly associated with partial fusion between the right coronary and noncoronary cusps, which facilitates creation of the new commissure with adequate cusp opening. The general tools of aortic valve repair will have to be applied as needed, e.g. external suture annuloplasty and prolapse correction according to effective height concept [5, 6]. Our current experience is still limited, but nonetheless, this procedure is a promising approach in selected patients.
6
References 1.
Anderson RH. Understanding the structure of the unicuspid and unicommissural aortic valve. J Heart Valve Dis 2003;12: 670–3.
2.
Novaro GM, Mishra M, Griffin BP. Incidence and echocar diographic features of congenital unicuspid aortic valve in an adult population. J Heart Valve Dis 2003;12:674–8.
3.
Schäfers HJ, Aicher D, Riodionycheva S, et al. Bicuspidization of the unicuspid aortic valve: a new reconstructive approach. Ann Thorac Surg 2008;85:2012–8.
4.
Aicher D, Bewarder M, Kindermann M, Abdul-Khalique H, Schäfers HJ. Aortic valve function after bicuspidization of the unicuspid aortic valve. Ann Thorac Surg 2013;95:1545–50.
5.
Franciulli M, Aicher D, Rädle-Hurst T, Takahashi H, Rodionycheva S, Schäfers HJ. Root remodeling and aortic valve repair for unicuspid aortic valve. Ann Thorac Surg 2014;98:823–9.
6.
Schneider U, Feldner SK, Hofmann C, et al. Two decades of experience with root remodeling and valve repair for bicuspid aortic valves. J Thorac Cardiovasc Surg 2017;153:S65–71.
7.
De Kerchove L, Momeni M, Aphram G, et al. Free margin length and coaptation surface area in normal tricuspid aortic valve: an anatomical study. Eur J Cardiothorac Surg 2018;53:1040–8.
7
Figure Legends Fig 1. Schematic diagrams of cusp nadir relocation. (A) Structure of the unicuspid aortic valve is inspected. The anterior cusp fusion is divided to extend cusp free margin (arrow). (B) Two symmetric tongues of a Dacron graft are sutured to each new cusp nadir (circle) relocated posteriorly (arrow). (C) The aortic valve obtains two symmetric commissures of sufficient height from a new angulated basal plane. Fig 2. Short-axis views of transesophageal echocardiography before procedure (A; systole, B: diastole) and after procedure (C: systole, D: diastole). Fig 3. Intraoperative photographs. (A) Exposure and inspection of the unicuspid aortic valve. (B) Two symmetric tongues of a Dacron graft are sutured to each new cusp nadir. (C) Two symmetric commissures of sufficient height are created. (D) The general tools for bicuspid aortic valve repair are applied to optimize the valve configuration.