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Modified Bentall Operation With Bioprosthetic Valved Conduit: Columbia University Experience
Modified Bentall Operation With Bioprosthetic Valved Conduit: Columbia University Experience Minoru Tabata, MD, MPH, Hiroo Takayama, MD, Michael E. Bowdish, MD, Craig R. Smith, MD, and Allan S. Stewart, MD
A conduit was made by sewing a bovine pericardial valve into a graft conduit with the pseudo-sinuses of Valsalva. The graft collar below the valve cuff ring was sewn to the aortic annulus with interrupted pledgeted sutures. From August 2005 to February 2008, 68 patients underwent aortic root replacements with this technique. Operative mortality was 2.9% (2 acute aortic dissection patients died). During median follow-up of 11 months, 1
patient had reoperation for conduit failure due to infectious endocarditis. This technique is safe and feasible with favorable early outcomes. Because the valve is sewn above the outflow tract, superior hemodynamics are achieved. Reoperation may be accomplished by removal of the valve rather than full root re-replacement. (Ann Thorac Surg 2009;87:1969 –70) © 2009 by The Society of Thoracic Surgeons
T
patient body size, we chose a valve one size larger, without annular enlargement. We used CarpentierEdwards Perimount heart valves (Edwards Lifesciences, Irvine, CA) and Gelweave Valsalva graft conduits (Terumo CardioVascular Systems Corp, Ann Arbor, MI) that were 5 mm larger in size than the valve. The prosthetic valve was inserted into the graft and sewn to the lower edge of the Valsalva sinus skirt with 4-0 polypropylene running sutures. The collar was then resected, leaving only approximately 2 mm of material. Non-everting pledgeted 2-0 polyester sutures were placed on the aortic annulus. Subsequently, those sutures were passed through the Valsalva graft collar below the sewing cuff of the prosthetic valve (Fig 1). The composite graft was seated down on the aortic annulus and sutures were tied down (Fig 2). Coronary buttons were reimplanted on the Valsalva sinus part of the conduit with 5-0 polypropylene running sutures. Median patient age was 66 years old (range, 32 to 89 years), 19 patients (30%) were women, and 9 (13%) had type A acute aortic dissection. Eleven patients (16%) had a history of previous cardiac surgery (5 had previous aortic valve replacement), 17 (25%) had concomitant procedures, such as total arch replacement, coronary artery bypass or mitral valve repair, and 45 patients had hypothermic circulatory arrest with antegrade cerebral perfusion. The median cardiopulmonary and aortic cross-clamp times were 139 and 98 minutes, respectively. The operative mortality was 2.9% (2 of 68). Both mortalities were in patients with type A dissection (ie, an 83-year-old man with a history of previous mitral valve repair and a 77-year-old man with a history of previous coronary artery bypass surgery). Two patients had reexploration for bleeding, one of them had bleeding from the removal of air from the needle hole on the prosthetic graft and the other had bleeding from the distal anastomosis. No patient had bleeding from the proximal anas-
he bioprosthetic valve is becoming a more common option for aortic valve disease, even in young patients, because the ill effects of systemic anticoagulation. However, a commercially available bioprosthetic valved conduit is not yet available in the United States. A handmade bioprosthetic composite graft has been shown safe and reproducible with excellent long-term results [1]. We report our experience with the modified Bentall operation using a bovine pericardial valve prosthesis and Valsalva graft conduit, constructed in a manner to provide superior hemodynamics and facilitate a less complicated reoperation.
Technique This study was approved by the Institutional Review Board of Columbia University, and a waiver of informed consent was obtained. Between August 2005 and February 2008, 68 patients underwent a modified Bentall operation at our institution. Perioperative data were collected from patient medical records. We applied this technique to patients whose aortic root and valve was not suitable for a valve-sparing root replacement. A median sternotomy approach was used in all cases. Cardiopulmonary bypass was established with aortic and axillary arterial and right atrial cannulation. On full cardiopulmonary bypass with mild to moderate hypothermia, an aortic cross clamp was placed and cardiac asystole was obtained in a standard fashion using antegrade and retrograde cardioplegia. The aortic root and aortic valve were resected and coronary buttons were made in a regular fashion. After sizing the aortic annulus, a valved conduit was constructed. If the size of annulus was too small for the Accepted for publication Sept 19, 2008. Address correspondence to Dr Stewart, Division of Cardiothoracic Surgery, Columbia University Medical Center, 177 Fort Washington Ave, New York, NY 10019; e-mail: [email protected].
© 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2008.09.055
FEATURE ARTICLES
Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, New York
1970
HOW TO DO IT TABATA ET AL MODIFIED BIOPROSTHETIC BENTALL OPERATION
Ann Thorac Surg 2009;87:1969 –70
tomosis. No patient had perioperative myocardial infarction or any complications related to coronary buttons. Median lengths of intensive care unit stay and postoperative hospital stay were 2 and 6 days, respectively. During a midterm follow-up (median period, 11 months), 1 patient had a reoperation due to graft and prosthetic valve endocarditis. The patient required re-replacement of the aortic root with a mechanical valved conduit.
Comment
FEATURE ARTICLES
This case series has shown that our modified Bentall operation is a safe and feasible technique. The Valsalva graft conduit has been recently used in many aortic root replacements including valve-sparing procedures. De Paulis and colleagues [2] have demonstrated the potential benefit of the pseudo-sinuses of Valsalva on the coronary flow after Bentall operations. They have also shown that the Valsalva conduit does not affect the prosthetic valve performance in their in-vitro study [3]. Theoretically, the Valsalva conduit reduces tension of coronary bottoms compared with the conventional tube graft. It also creates more space between the bioprosthetic valve struts and coronary buttons and may decrease the risk of coronary button complications. Passing the annular sutures through the graft collar is the major advantage of this technique. Because the valve is seated above the aortic annulus, this technique allows a surgeon to place a larger size valve than the annulus, which especially helps patients with a small aortic annulus. The effective orifice area becomes the left ventricular outflow tract, not the internal diameter of the prosthetic valve. The valve position is slightly higher compared with a technique passing the annular sutures through the valve cuff; however, coronary buttons do not need to be
Fig 2. A composite graft is seated on the annulus. The valve is situated above the aortic annulus.
placed higher, because the Valsalva graft creates space between the valve and the graft wall. Albertini and colleagues [4] have recently reported a similar technique. As they described, these techniques may allow a surgeon to reoperate on the valve only, without compromising the root structure when the prosthetic valve has become degenerated. The use of the Valsalva graft allows for a larger space in the root to facilitate both resection of the old valve and replacement of a new prosthesis. The limitation of this study is its observational noncomparative nature. We did not compare the outcomes of this technique to those of conventional Bentall procedures or quantify the effect of this specific technique. However, the potential benefits of this technique have biological rationale, and we have shown that our modification does not compromise early operative outcomes. Further follow-up is necessary to evaluate its long-term risk and benefit. In conclusion, our modified Bentall procedure is safe and feasible with good early outcomes. It may decrease the risk of coronary button-related complications. It increases the valve size to an area equivalent to the outflow tract by eliminating the contribution of the sewing cuff. It may also facilitate the valve replacement without compromising a root graft in reoperations.
References
Fig 1. A 2-0 polyester suture is passed through the composite graft collar below the sewing cuff of the prosthetic valve.
1. Etz CD, Homann TM, Rane N, et al. Aortic root reconstruction with a bioprosthetic valved conduit: a consecutive series of 275 procedures. J Thorac Cardiovasc Surg 2007;133:1455– 63. 2. De Paulis R, Tomai F, Bertoldo F, et al. Coronary flow characteristics after a Bentall procedure with or without sinuses of Valsalva. Eur J Cardiothorac Surg 2004;26:66 –72. 3. De Paulis R, Schmitz C, Scaffa R, Nardi P, Chiariello L, Reul H. In vitro evaluation of aortic valve prosthesis in a novel valved conduit wit pseudosinuses of Valsalva. J Thorac Cardiovasc Surg 2005;130:1016 –21. 4. Albertini A, Dell’Amore A, Zussa C, Lamarra M. Modified Bentall operation: the double sewing ring technique. Eur J Cardiothorac Surg 2007;32:804 – 6.
A conduit was made by sewing a bovine pericardial valve into a graft conduit with the pseudo-sinuses of Valsalva. The graft collar below the valve cuff ring was sewn to the aortic annulus with interrupted pledgeted sutures. From August 2005 to February 2008, 68 patients underwent aortic root replacements with this technique. Operative mortality was 2.9% (2 acute aortic dissection patients died). During median follow-up of 11 months, 1
patient had reoperation for conduit failure due to infectious endocarditis. This technique is safe and feasible with favorable early outcomes. Because the valve is sewn above the outflow tract, superior hemodynamics are achieved. Reoperation may be accomplished by removal of the valve rather than full root re-replacement. (Ann Thorac Surg 2009;87:1969 –70) © 2009 by The Society of Thoracic Surgeons
T
patient body size, we chose a valve one size larger, without annular enlargement. We used CarpentierEdwards Perimount heart valves (Edwards Lifesciences, Irvine, CA) and Gelweave Valsalva graft conduits (Terumo CardioVascular Systems Corp, Ann Arbor, MI) that were 5 mm larger in size than the valve. The prosthetic valve was inserted into the graft and sewn to the lower edge of the Valsalva sinus skirt with 4-0 polypropylene running sutures. The collar was then resected, leaving only approximately 2 mm of material. Non-everting pledgeted 2-0 polyester sutures were placed on the aortic annulus. Subsequently, those sutures were passed through the Valsalva graft collar below the sewing cuff of the prosthetic valve (Fig 1). The composite graft was seated down on the aortic annulus and sutures were tied down (Fig 2). Coronary buttons were reimplanted on the Valsalva sinus part of the conduit with 5-0 polypropylene running sutures. Median patient age was 66 years old (range, 32 to 89 years), 19 patients (30%) were women, and 9 (13%) had type A acute aortic dissection. Eleven patients (16%) had a history of previous cardiac surgery (5 had previous aortic valve replacement), 17 (25%) had concomitant procedures, such as total arch replacement, coronary artery bypass or mitral valve repair, and 45 patients had hypothermic circulatory arrest with antegrade cerebral perfusion. The median cardiopulmonary and aortic cross-clamp times were 139 and 98 minutes, respectively. The operative mortality was 2.9% (2 of 68). Both mortalities were in patients with type A dissection (ie, an 83-year-old man with a history of previous mitral valve repair and a 77-year-old man with a history of previous coronary artery bypass surgery). Two patients had reexploration for bleeding, one of them had bleeding from the removal of air from the needle hole on the prosthetic graft and the other had bleeding from the distal anastomosis. No patient had bleeding from the proximal anas-
he bioprosthetic valve is becoming a more common option for aortic valve disease, even in young patients, because the ill effects of systemic anticoagulation. However, a commercially available bioprosthetic valved conduit is not yet available in the United States. A handmade bioprosthetic composite graft has been shown safe and reproducible with excellent long-term results [1]. We report our experience with the modified Bentall operation using a bovine pericardial valve prosthesis and Valsalva graft conduit, constructed in a manner to provide superior hemodynamics and facilitate a less complicated reoperation.
Technique This study was approved by the Institutional Review Board of Columbia University, and a waiver of informed consent was obtained. Between August 2005 and February 2008, 68 patients underwent a modified Bentall operation at our institution. Perioperative data were collected from patient medical records. We applied this technique to patients whose aortic root and valve was not suitable for a valve-sparing root replacement. A median sternotomy approach was used in all cases. Cardiopulmonary bypass was established with aortic and axillary arterial and right atrial cannulation. On full cardiopulmonary bypass with mild to moderate hypothermia, an aortic cross clamp was placed and cardiac asystole was obtained in a standard fashion using antegrade and retrograde cardioplegia. The aortic root and aortic valve were resected and coronary buttons were made in a regular fashion. After sizing the aortic annulus, a valved conduit was constructed. If the size of annulus was too small for the Accepted for publication Sept 19, 2008. Address correspondence to Dr Stewart, Division of Cardiothoracic Surgery, Columbia University Medical Center, 177 Fort Washington Ave, New York, NY 10019; e-mail: [email protected].
© 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2008.09.055
FEATURE ARTICLES
Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, New York
1970
HOW TO DO IT TABATA ET AL MODIFIED BIOPROSTHETIC BENTALL OPERATION
Ann Thorac Surg 2009;87:1969 –70
tomosis. No patient had perioperative myocardial infarction or any complications related to coronary buttons. Median lengths of intensive care unit stay and postoperative hospital stay were 2 and 6 days, respectively. During a midterm follow-up (median period, 11 months), 1 patient had a reoperation due to graft and prosthetic valve endocarditis. The patient required re-replacement of the aortic root with a mechanical valved conduit.
Comment
FEATURE ARTICLES
This case series has shown that our modified Bentall operation is a safe and feasible technique. The Valsalva graft conduit has been recently used in many aortic root replacements including valve-sparing procedures. De Paulis and colleagues [2] have demonstrated the potential benefit of the pseudo-sinuses of Valsalva on the coronary flow after Bentall operations. They have also shown that the Valsalva conduit does not affect the prosthetic valve performance in their in-vitro study [3]. Theoretically, the Valsalva conduit reduces tension of coronary bottoms compared with the conventional tube graft. It also creates more space between the bioprosthetic valve struts and coronary buttons and may decrease the risk of coronary button complications. Passing the annular sutures through the graft collar is the major advantage of this technique. Because the valve is seated above the aortic annulus, this technique allows a surgeon to place a larger size valve than the annulus, which especially helps patients with a small aortic annulus. The effective orifice area becomes the left ventricular outflow tract, not the internal diameter of the prosthetic valve. The valve position is slightly higher compared with a technique passing the annular sutures through the valve cuff; however, coronary buttons do not need to be
Fig 2. A composite graft is seated on the annulus. The valve is situated above the aortic annulus.
placed higher, because the Valsalva graft creates space between the valve and the graft wall. Albertini and colleagues [4] have recently reported a similar technique. As they described, these techniques may allow a surgeon to reoperate on the valve only, without compromising the root structure when the prosthetic valve has become degenerated. The use of the Valsalva graft allows for a larger space in the root to facilitate both resection of the old valve and replacement of a new prosthesis. The limitation of this study is its observational noncomparative nature. We did not compare the outcomes of this technique to those of conventional Bentall procedures or quantify the effect of this specific technique. However, the potential benefits of this technique have biological rationale, and we have shown that our modification does not compromise early operative outcomes. Further follow-up is necessary to evaluate its long-term risk and benefit. In conclusion, our modified Bentall procedure is safe and feasible with good early outcomes. It may decrease the risk of coronary button-related complications. It increases the valve size to an area equivalent to the outflow tract by eliminating the contribution of the sewing cuff. It may also facilitate the valve replacement without compromising a root graft in reoperations.
References
Fig 1. A 2-0 polyester suture is passed through the composite graft collar below the sewing cuff of the prosthetic valve.
1. Etz CD, Homann TM, Rane N, et al. Aortic root reconstruction with a bioprosthetic valved conduit: a consecutive series of 275 procedures. J Thorac Cardiovasc Surg 2007;133:1455– 63. 2. De Paulis R, Tomai F, Bertoldo F, et al. Coronary flow characteristics after a Bentall procedure with or without sinuses of Valsalva. Eur J Cardiothorac Surg 2004;26:66 –72. 3. De Paulis R, Schmitz C, Scaffa R, Nardi P, Chiariello L, Reul H. In vitro evaluation of aortic valve prosthesis in a novel valved conduit wit pseudosinuses of Valsalva. J Thorac Cardiovasc Surg 2005;130:1016 –21. 4. Albertini A, Dell’Amore A, Zussa C, Lamarra M. Modified Bentall operation: the double sewing ring technique. Eur J Cardiothorac Surg 2007;32:804 – 6.