- Email: [email protected]
Surgical Correction of Ascending Aortic Aneurysm and Aortic Valve Incompetence by Relocation of the Aortic Valve Plane Using a Short Aortic Replacement Graft
Roland Hetzer, MD, PhD, Natalia Solowjowa, MD, Christoph Knosalla, MD, PhD, Marian Kuckuka, MD, and Eva Maria B. Delmo Walter, MD, PhD Deutsches Herzzentrum Berlin, Berlin, Germany
Background. Ascending aortic aneurysms grow circumferentially and longitudinally. This geometric dislocation with widening, flattening, or loss of the sinotubular junction by aortic dilatation distorts and causes incompetence of even a structurally normal valve. We described a technique of surgical correction of ascending aortic aneurysm and valve incompetence by relocating the displaced aortic annulus plane to its normal anatomic position. Methods. Between 1998 and 2011, 48 patients (median age, 66.5; range, 7 to 82 years) with ascending aortic aneurysm and elongation and severe aortic valve incompetence underwent ascending aortic replacement. The aneurysm was incised longitudinally, and an appropriately sized straight Dacron (DuPont, Wilmington, DE) graft was sutured onto the aorta approximately 5 mm above the commissures, recreating the sinotubular junction. When valve competence was assured, the graft, cut considerably shorter than the original length of the
ascending aorta, was anastomosed distally. The valve plane was hence relocated in a more cranial/oblique position, restoring its normal alignment. Perioperative echocardiographic and computed tomography studies were done to document the degree of aortic valve incompetence and the morphology of the aortic root. Results. During a mean follow-up of 3.0 ⴞ 2.7 years, aortic insufficiency was absent to trivial in 34, mild in 12, and moderate in 2 patients. Postoperative computed tomography showed considerable aortic shortening, remarkable sinotubular junction narrowing, aortic root diameter reduction, and angular widening between the aortic root plane and longitudinal spinal axis corresponding to aortic incompetence reduction. Conclusions. Aortic relocation technique provided satisfactory results in management of ascending aortic aneurysm and elongation with aortic valve incompetence. (Ann Thorac Surg 2012;94:1983–9) © 2012 by The Society of Thoracic Surgeons
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Understanding the pathophysiology of aortic root aneurysm and morphology of the aortic valve in this disease entity, precise knowledge of the anatomic and geometric relationships among the various components of the aortic root, and a thorough understanding of the mechanism of valve incompetence in this setting is indispensable and the key to a satisfactory outcome of an aortic valve– sparing operation. Ascending aortic aneurysms grow circumferentially and longitudinally. Longitudinal growth affects the ascending aorta asymmetrically, being more conspicuous on the right side, hence shifting the valve annulus plane from its original oblique position relative to the longitudinal body axis into a more parallel position [10, 11] (Fig 1A). This geometric dislocation distorts the valve and may cause prolapse of the noncoronary cusp and incompetence of a structurally normal valve. Widening, flattening, or loss of the sinotubular junction by aortic dilatation may further add to impaired leaflet coaptation. This report describes a technique of surgical correction of ascending aortic aneurysm and aortic valve incompetence by relocating the displaced aortic valve annulus
ince the introduction of aortic remodeling technique by Fagan and colleagues [1] in 1982 and the reimplantation technique by David and Feindel [2] in 1992, aortic valve-sparing operations to treat patients with aortic root pathologies have gained interest. Both surgical strategies support the wall of the aortic root to different magnitudes. Various modifications of the techniques initiated by Yacoub and David to improve functional characteristics of the aortic valve have evolved [3– 8], which have been theoretically appealing, with excellent early results. A longer-term follow-up, especially of aortic valve function over time, is mandatory to assess these different methods [9]. At present, none of these procedures has been able to meet the complexity of aortic root and valve function in its entirety, rendering the durability of the repair questionable.
Accepted for publication July 16, 2012. Presented at the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25–27, 2010. Address correspondence to Dr Delmo Walter, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.07.043
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Surgical Correction of Ascending Aortic Aneurysm and Aortic Valve Incompetence by Relocation of the Aortic Valve Plane Using a Short Aortic Replacement Graft
1984
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Ann Thorac Surg 2012;94:1983–9
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Fig 1. (A) Graphic representation of the mechanism of asymmetric aneurysmal growth of the ascending aorta, with shift of the aortic root towards the left to a position parallel to the vertebral column. (B) Replacing the aneurysmal ascending root with a short graft, relocating the aortic valve plane upwards, and recreating the sinotubular junction. Measured computerized tomography scan dimensions are: A, distance between the deepest point of noncoronary sinus and right inferior rim of the take-off of the brachiocephalic trunk; B, distance between the left coronary ostium and the left inferior rim of the take-off of left subclavian artery; C, diameter of presumed new sinotubular junction; D, diameter of aortic root at level of coronary ostia; and E, angle between coronary ostial plane and sagittal spine plane.
plane to its normal anatomic position. This is achieved by replacement of the ascending aorta with a vascular graft considerably shorter than the original aortic length, with a graft diameter that equals the size of the inner valve annulus, hence recreating a supravalvular narrowing at the site of the sinotubular junction.
Patients and Methods The Institutional Review Board approved this study and patient consent was obtained for the planned surgical strategy of aortic valve preservation and possible valve replacement.
Patients Between November 1998 and September 2011, 48 patients (male/female ratio, 1:1), with ascending aortic aneurysm, elongation, and variable degree of incompetence of a structurally normal aortic valve (grade I-IV), underwent ascending aortic replacement. Patients were a mean age of 62.5 years (median, 66.5; range, 7 to 82 years). The study excluded 11 patients (10 men; mean age, 57.09; range, 46 to 65 years). In 5 patients, intraoperative assessment of aortic valve competence after the procedure demonstrated persistence of insufficiency; hence, a decision to replace the aorta with a valved conduit was made. In the other 6 patients, intraoperative inspection of the aortic valve showed aneurysm of the sinus of Valsalva in 2 patients and annular dilatation with calcified right coronary leaflet, annular dilation and severely thinnedout aortic root, prolapse of left coronary leaflet, and calcified left and noncoronary leaflet with prolapse in 1 patient each. The planned aortic relocation was not even attempted in these patients, but straightforward ascending aortic root and valve replacement was done. Preoperative echocardiographic and computed tomography (CT) studies were done. CT (Siemens Somatom Definition machine, Munich, Germany) data were recon-
structed and analyzed using 3-dimensional (3D), Inspace and circulation postprocessing tools (Siemens Leonardo Workstation). Volume-rendering technique was used for spatial measurements and dynamic reconstructions; 3D and circulation tools were used for morphologic, anatomic, and functional assessment of the aortic valve and ascending aorta. Figure 1B shows the CT scan-measured dimensions we were interested in: A is the distance between the deepest point of noncoronary sinus and right inferior rim of the take-off of the brachiocephalic trunk; B is the distance between left coronary ostium and the left inferior rim of the take-off of the left subclavian artery; C is the diameter of the presumed new sinotubular junction; D is the diameter of aortic root at level of coronary ostia; and E is the angle between coronary ostial plane and sagittal spine plane.
Surgical Technique The operation was performed through a median sternotomy under total cardiopulmonary bypass except in 3 patients with concomitant aortic arch replacement, in whom deep hypothermia (16°C), low flow perfusion through the femoral artery, and selective cerebral perfusion through the brachiocephalic trunk were used. In patients with isolated ascending aortic aneurysms, the aortic arch and the right atrium were cannulated with a left ventricular vent catheter introduced through the right upper pulmonary vein. Except in patients with concomitant arch replacement, the ascending aorta was clamped just below the take-off of the brachiocephalic trunk. The ascending aortic root aneurysm was incised longitudinally directed toward the noncoronary sinus to a point halfway between the cranial tips of the neighboring commissures. The sinuses were inspected beforehand, taking note of the symmetry of dilatation. In this series, all 3 coronary sinuses were dilated symmetrically in 13 patients, the noncoronary sinus was most dilated in
HETZER ET AL SHORT GRAFT FOR AORTIC VALVE PLANE RELOCATION
28, the left coronary sinus was most dilated in 5, and the right coronary sinus was most dilated in 2. Blood cardioplegia, infused directly through the coronary ostia, repeated every 20 minutes, was used for myocardial protection. The aortic valve was carefully inspected and tested for competence. A decision to preserve the valve was made when the valve was found to be structurally normal with good leaflet coaptation. The inner diameter of the valve annulus was measured to choose a straight Dacron (DuPont, Wilmington, DE) vascular graft that matched the measured inner diameter. Then this graft was proximally anastomosed to the aorta approximately 5 mm above the commissures using a continuous suture of polypropylene 4-0. The competence of the aortic valve was tested by infusing blood cardioplegic solution into the graft under pressure and by pulling the aortic valve annulus toward the arch. When aortic valve competence was assured, the graft was cut to a length considerably shorter than the original aortic length and to a degree that maintained the aortic valve competence under pressured cardioplegia infusion. The distal aortic anastomosis was performed using continuous suture with a polypropylene 4-0. The graft inclusion technique, with wrapping of the aneurysmal wall around the implanted graft, was used in all patients. Intraoperative transesophageal echocardiography (Fig 2) was used routinely to assess and document the aortic valve competence and the morphology of the aortic root before and after the procedure.
Follow-Up
1985
All patients were prospectively monitored. Serial echocardiographic studies to assess aortic valve competence were done throughout the follow-up period. The CT scan variables (see “Patients” and Fig 1B) were measured postoperatively and at the latest follow-up.
Statistical Analysis Discrete data are expressed as absolute and percentage frequency values and continuous data as mean ⫾ standard deviation or median and range, as appropriate. Repeated measurements of echocardiographic variables, including aortic valve area (cm2), annulus size (cm), and leaflet area (cm) in serial timelines, were analyzed with Friedman tests. Mann-Whitney U test was used to facilitate comparison between preoperative and follow-up CT scan dimensions. A p value of 0.05 or less was considered significant. Freedom from reoperation and cumulative survival rates were analyzed according to Kaplan-Meier estimates with the 95% confidence interval (CI). All data were analyzed with SPSS 16.0 software (SPSS Inc, Chicago IL).
Results Postoperative Course No postoperative morbidity or 30-day hospital deaths occurred. Late deaths included a patient who died of ruptured descending aortic aneurysm at 42 days and a Fig 2. (A) Intraoperative transesophageal echocardiogram before the relocation procedure shows extensive ascending aortic aneurysm, loss of the sinotubular junction and normal valve leaflets. (B) The Doppler studies show massive aortic incompetence. Imaging after relocation shows (C) new sinotubular narrowing at the proximal anastomosis of the graft and (D) a very competent aortic valve.
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Ann Thorac Surg 2012;94:1983–9
patient who died of pneumonia at 66 days. At 12 years after the initial aortic root replacement, a patient underwent reoperation for progression of an aortic arch aneurysm and died 40 days after the second operation.
Since this initial successful case with favorable longterm results, the technique has been used in a consecutive series of 48 patients with ascending aortic aneurysm with aortic valve incompetence. Hence, we recognized that restoration of orientation and location of the aortic valve plane restores the geometry of the sinotubular junction, which is often flattened by the aneurysm. This distortion thus causes leaflet prolapse, leading to impaired leaflet coaptation. We believe that restoration of a supravalvular narrowing at the site of the sinotubular junction is important in maintaining valve competence. Relocating the width of the aortic root at the widest extension of the sinuses by a shorter graft reengineers the normal alignment of the valve relative to the aortic root. This aortic valve relocation technique and the mechanism of restoration of valve competence in ascending aortic root aneurysm was first mentioned in a review article in 2007 [10] and presented at the Forty-sixth Annual Meeting of the Society of Thoracic Surgeons in January 2010 [11]. In aortic root aneurysm, isolated dilation of the aortic sinuses does not cause aortic valve incompetence [20]. However, it alters the anatomic relationships of the various components of the aortic root, which is why patients with aortic root aneurysms may have entirely competent aortic valves. As the sinotubular junction or aortic annulus, or both, dilate, the coaptation area of the cusps decreases, and valve incompetence ensues. Dilatation of these structures increases the mechanical stress on the aortic cusps, which thin and stretch, leading to development of stress fenestrations along the commissures. Depending on the extent and degree of damage, the aortic cusps may be beyond salvage. Likewise, lengthening and distortion of the aortic base may cause prolapse of mainly the noncoronary leaflet, of which the mechanism is similar to aortic incompetence in acute type A dissection, when the inner layer of the aorta bearing one or two of the aortic valve commissures (usually the ones near the noncoronary cusp) shifts down toward the left ventricular cavity. In this context, valve competence can be restored by suspension of the aortic valve during the ascending aorta replacement. In chronic aortic root aneurysm, it is not only the restoration of the location and orientation of the valve that is of utmost importance; rather, the restoration of a sinotubular junction must also be considered. The aortic narrowing at the sinotubular junction, just beyond the commissures, is necessary for good leaflet coaptation and valve closure. This concept was recognized by Leonardo da Vinci [12] and several modern investigators [24 –26].
Follow-Up During a mean follow-up of 3.0 ⫾ 2.7 years (median, 2.3 years; range, 11 months to 12.2 years; 1,487 patient-years), aortic valve incompetence was absent to trivial in 34 patients, mild in 12, and moderate in 2. Table 1 reports the preoperative and postoperative aortic dimensions measured by CT scan. Remarkably significant postoperative changes (p ⬍ 0.001) occurred in all measured CT variables as follows: A, ⫺20.3% ⫾ 8.9%; B, ⫺14.3% ⫾ 6.5% (both A and B show that there is a considerable shortening of the aorta); C, ⫺40.8% ⫾ 9.0% (sinotubular junction became smaller); D, ⫺14.9% ⫾ 9.3% (diameter of the aortic root is significantly smaller); and E, ⫹52.0% ⫾ 40.5% (angle between the aortic root plane and longitudinal axis of the spine became wider, which corresponds to reduction of aortic incompetence (AI ⌬ mean, 1.9; Fig 3A and B). The present freedom from reoperation is 100% and cumulative survival is 93.7%.
Comment To this date, several authors have contributed much to the knowledge of aortic root function and the sinotubular junction, including Da Vinci [12] (1513), Corrigan [13] (1832), Reid [14] (1970), Bellhouse [15] (1973), Frater [16] (1986), Thubrikar [17] (1981), Robicsek [13] (1991), Kunzelman [18] (1994), David [19] (1995), and Furukawa [20] (1999). The surgical technique that has gained much popularity is that of David’s aortic valve–sparing operations, which have evolved from the accumulated knowledge of anatomy, physiology, pathology, and surgical experience [21–24]. In 1998, while operating on a patient with an ascending aortic aneurysm and aortic valve incompetence, on which an ascending aortic root and valve replacement was initially planned, an entirely normal aortic valve with tender, mobile, and well-coaptating leaflets was found. We searched for the cause of valve dysfunction, and in so doing, recognized that the valve became competent by elevating it at its noncoronary sinus. We thus opted for a supracoronary ascending aortic replacement with a graft shorter than the original length of the ascending aorta, which at the same time restored the valve competence. The technique was then termed aortic valve relocation.
Table 1. Perioperative Aortic Root Dimensions Based on Computed Tomography Scan Measurements Dimension A. Distance between noncoronary sinus and rim of brachiocephalic trunk B. Distance between left coronary ostium and rim of left subclavian artery C. Diameter of sinotubular junction D. Diameter of the aortic root at coronary ostia E. Angle between coronary ostial plane and sagittal spine plane
Preoperative (mm)
Postoperative (mm)
120.5 ⫾ 12.8 102.2 ⫾ 13.2 45.4 ⫾ 7.6 41.9 ⫾ 5.9 45.5 ⫾ 10.01
95.4 ⫾ 12.1 87.2 ⫾ 11.9 26.3 ⫾ 2.4 35.2 ⫾ 4.1 65.5 ⫾ 12.0
% Change –20.3 ⫾ 8.9 ⫺14.3 ⫾ 6.5 ⫺40.8 ⫾ 9 ⫺14.9 ⫾ 9.3 52.0 ⫾ 40.5
Fig 3. Four-dimensional computed tomography scan reconstructions show the aortic annular angle (A) before and (B) after the aortic relocation procedure.
Ascending aortic aneurysm causes aortic valve insufficiency because of the dilatation of the sinotubular junction, which pulls the cusps apart and hinders central coaptation. These cusps usually remain normal, although occasionally the free margins of one or more cusps become elongated because of the increased stress caused by the dilation of the sinotubular junction. The significance of sinotubular junction in aortic valve closure has been acknowledged by many authors [15, 27–29] since Leonardo da Vinci’s postulate that its presence, by creating eddy currents and a small pressure
HETZER ET AL SHORT GRAFT FOR AORTIC VALVE PLANE RELOCATION
1987
gradient across the aortic and ventricular aspects of the leaflets, contributes to smooth and coordinated valve closure. Robicsek [30] and Makhijani and colleagues [31], as well as Thubrikar and colleagues [32], confirmed in their series of experimental studies the beneficial effects of the sinuses of Valsalva on aortic valve dynamics. That the functional unit of the semilunar valve is not the leaflets alone but includes the leaflets’ commissural suspension and its corresponding sinus as well was demonstrated by Robicsek and Thubrikar [33] in their wellcontrolled experiments. They found that the presence of 3 compliant sinuses assures a physiologic systolic expansion and diastolic shortening of the diameter of the normal aortic root, generating a “pull-and-release” commissural function that contributes to a smooth, gradual, and symmetrical opening of the leaflets during systole and synchronous coordinated leaflet approximation during diastole. Although the aortic root still maintains the basic hemodynamics in pressure-flow relations and valve competence, the modulated function of the sinotubular junction and sinuses, which is perfect in the normal aortic root, is greatly disturbed in aortic root aneurysm, hence contributing significantly to the valve incompetence. In our aortic valve relocation technique, we ensure that the width of the sinotubular junction must equal the diameter of the prosthetic vascular graft, the appropriate size of which is measured intraoperatively to match the inner diameter of the aortic valve annulus. Relocating the aortic valve to its normal anatomic position and orientation relative to the aortic root by implanting a graft considerably shorter than the original length of the ascending aorta completely restored its competence in these 48 patients with supracoronary ascending aneurysm, elongation of the aorta, and aortic valve incompetence in an entirely structurally normal valve. The absence of reoperation during the midterm and long-term follow-up shows that relocation provides effective and long-lasting functional valve competence and obviates the need for complicated valve repair procedures or even valve replacement. In conclusion, ascending aortic aneurysm and elongation with incompetence of the aortic valve can be successfully treated by replacement with a short graft, relocating the valve plane to its normal position and alignment, as shown by the angle between the aortic valve plane and the spine, and recreating the sinotubular junction, hence restoring the competence of a normally structured aortic valve. We have shown that restoration of the supravalvular narrowing at the sinotubular junction is precisely important for valve competence. Likewise, we have shown that the effect of restoring and relocating the width of the aortic root at the widest extension of the sinuses is an effective remodelling process. This technique has been promising in Marfanrelated annuloaortic ectasia or even in bicuspid valves, of which clinical studies are currently being done in our institution.
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We greatly appreciate the assistance of Christine Detschades, Julia Stein, and Astrid Benhennour, and thank Anne Gale for editing the manuscript. ADULT CARDIAC
References 1. Fagan A, Yacoub MH, Pillai R, Radley-Smith R. Dacron replacement of the ascending aorta and sinuses with resuspension of the aortic valve and reimplantation of the coronary arteries: a new method for treatment of aneurysmal or acute dissection of the aortic root. Proceedings of the Joint International Cardiovascular and Thoracic Surgical Conference, Stockholm (abstract). Scand J Cardiothorac Surg 1982; 16:175. 2. David TE, Feindel CM. An aortic valve-sparing operations for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617–21. 3. Sarsam MA, Yacoub M. Remodeling of the aortic valve annulus. J Thorac Cardiovasc Surg 1993;105:435– 8. 4. Miller DC. Valve-sparing aortic root replacement in patients with Marfan’s syndrome. J Thorac Cardiovasc Surg 2003;125: 773– 8. 5. Erasmi A, Sievers HH, Scharfshwerdt M, Eckel T, Misfeld M. In vitro hydrodynamics, cusp-bending deformation, and root distensibility for different types of aortic valve-sparing operations: remodeling, sinus prosthesis, and reimplantation. J Thorac Cardiovasc Surg 2005;130:1044 –9. 6. Hetzer R, Komoda T, Komoda S, Berger F, Huebler M. New aortic root remodeling surgery in aortic root aneurysm. Ann Thorac Surg 2010;89:1260 – 4. 7. De Paulis R, De Mattheis GM, Nardi P, Scaffa R, Buratta MM, Chiariello L. Opening and closing characteristics of the aortic valve after valve-sparing procedures using a new aortic root conduit. Ann Thorac Surg 2001;72:487–94. 8. Hetzer R, Komoda S, Komoda T. Remodeling of aortic root by annular reconstruction and plication of sinuses of Valsalva. J Card Surg 2008;23:49 –51. 9. Akins CW, Miller DC, Turina MI, et al. Guidelines for reporting mortality and morbidity after cardiac valve interventions. Ann Thorac Surg 2008;85:1490 –5. 10. Hetzer R, Pasic M, Eichstädt H. Chirurgie des aorta ascendens und des Aortenbogens. Herzmedizin 2007;4:175– 82. 11. Hetzer R, Solowjowa N, Kukucka M, Knosalla C, Röttgen R. Correction of aortic valve competence combined with ascending aortic aneurysm by relocation of the aortic valve plane through a short-length aorti-graft replacement. In: Yankah, CA, Weng Y, Hetzer R, editors. Aortic root surgery: the biological solution. Berlin Heidelberg New York: Springer Verlag; 2010:177– 84. 12. Keele KD, Pedretti C, eds. Leonardo da vinci. Corpus of the anatomical sudies in the collection of her majesty, the queen, at Windsor Castle. London, New York: Johnson reprint, Harcourt Brace Jovanovich; 1978 –1980. 13. Robicsek F. Leonardo da Vinci and the sinuses of Valsalva. Ann Thorac Surg 1991;52:328 –35. 14. Reid K. The anatomy of the sinus of Valsalva. Thorax 1970;25:79 – 85.
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15. Bellhouse BJ, Bellhouse F, Abbott JA, Talbot L. Mechanism of valvular incompetence in aortic sinus dilatation. Cardiovasc Res 1973;7:490 – 4. 16. Frater RW. Aortic valve insufficiency due to aortic dilatation: correction by sinus rim adjustment. Circulation 1986;74: I136 – 42. 17. Thubrikar M, Piepgrass WC, Shaner TW, Nolan SP. The design of the normal aortic valve. Am J Physiol 1981;241: H795– 801. 18. Kunzelman KS, Grande KJ, David TE, Cochran RP, Verrier ED. Aortic root and valve relationships. Impact on surgical repair. J Thorac Cardiovasc Surg 1994;107:162–70. 19. David TE, Feindel CM, Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm.J Thorac Cardiovasc Surg 1995;109:345–51; discussion 351–2. 20. Furukawa K, Ohteki H, Cao ZL, et al. Does dilatation of the sinotubular junction cause aortic regurgitation? Ann Thorac Surg 1999;68:949 –53; discussion 953– 4. 21. David TE. Surgical treatment of ascending aorta and aortic root aneurysms. Prog Cardiovasc Dis 2010;52:438 – 44. 22. David TE, Maganti M, Armstrong S. Aortic root aneurysm: principles of repair and long-term follow-up. J Thorac Cardiovasc Surg 2010;140:S14 –9. 23. David TE. How I do aortic valve sparing operations to treat aortic root aneurysm. J Card Surg 2011;26:92–9. 24. Grande-Allen KJ, Cochran RP, Reinhall PG, Kunzelmann KS. Re-creation of sinuses is imprtant for sparing the aortic valve: a finite element study. J Thorac Cardiovasc Surg 2000;119:753– 63. 25. Zehr KJ, Thubrikar MJ, Gong GG, Headrick JR, Robicsek F. Clinical introduction of a novel prosthesis for valvepreserving aortic root reconstruction for annuloaortic ectasia. J Thorac Cardiovasc Surg 2000;120:692– 8. 26. Demer P, Miller DC. Simple modification of “T. David-V” valve sparing aortic root replacement to create graft pseudosinuses. Ann Thorac surg 2004;78:1479 – 81. 27. Peskin CS, Wolfe AW. The aortic sinus vortex. Fed Proc 1978;37:2784 –92. 28. Von Steenhoven AA, Verlaan CWJ, Veenstra PC, Reneman RS. In vivo cinematographic analysis of the behavior of the aortic valve. Am J Physiol 1981;240:H286 –92. 29. Henderson Y, Johnson FE. Two modes of closure of heart valves. Heart 1912;4:69 – 82. 30. Robicsek F. Leonardo da Vinci’s anatomical drawings. In: Grossi A, Donatelli F, Como A, Brodman R, eds. Cardiology and cardiac surgery: current topics. Mount Kisco, NY: Futura Publishing Co Inc; 1992:3–29. 31. Makhijani V, Yang HQ, Donne PJ, Thubrikar MJ. Threedimensional coupled fluid-structure simulation of pericardial bioprosthetic aortic valve function. ASIAO J 1997;43: M387–92. 32. Thubrikar MJ, Robicsek F, Beck A. Stress analysis of the aortic valve with and without the sinuses of Valsalva. Presented at: World Symposium on Heart Valve Disease, London, June 1999:248. 33. Robicsek F, Thubrikar MJ. Role of sinus wall compliance in aortic leaflet function. Am J Cardiol 199;84:944 – 46.
DISCUSSION DR JOHN S. IKONOMIDIS (Charleston, SC): Dr Hetzer, this patient population is obviously a small number from a much larger patient population. Can you give us some insights into what the preoperative assessments were that made you confident that you would be able to achieve competence of the aortic valve just with sinotubular junction remodeling alone and relocation of the valve? I ask because, looking at the case that you presented, I might have been inclined to do a valve-sparing
root replacement on that patient rather than just sinotubular junction remodeling. DR HETZER: Pardon me? DR IKONOMIDIS: The patient that you presented, looked to me like a good candidate for a valve-sparing root replacement as opposed to a supracoronary graft, but you clearly achieved
HETZER ET AL SHORT GRAFT FOR AORTIC VALVE PLANE RELOCATION
success with the supracoronary graft. Could you tell us a little bit about how you assess these patients for that procedure?
junction leaflets are the most significant factors. It may well be that the sinotubular junction ridge really plays a major role.
DR HETZER: Of course. We have a fairly large aortic program with roughly 400 to 500 cases per year, and this is very small selection. As you have seen, I did this one case 11 years ago, and then I sort of forgot about it. It came up again when this combination of ascending aortic aneurysm and incompetent valve was presented, and the echocardiographer told me that the valve was entirely normal. That means the valve leaflets were entirely normal, and it is true, the patient had like grade II or III aortic incompetence. And then I said, okay, let’s have a look at it, and when opening the aortic aneurysm, we then saw that the valve was entirely normal. And by just trying to move the base around, it became clear that by just lifting it up, the leaflets would coapt. As I said, this is a very selected subset of cases here, because we wanted to make sure that we didn’t have any failures and significant incompetence afterwards. There were cases where we changed during the operation when we saw, doing the initial testing, that the significant incompetence was present. I think we have to further study those cases. And as I said in the end, we are not quite sure yet whether the elongation, the displacement, or the sinotubular
DR R. SCOTT MITCHELL (Stanford, CA): Continuing that investigation, are there echocardiographic features, say specifically, asymmetric sinus enlargement, that you can determine and that correlates, and to follow that, postoperative echocardiographic or computed tomography analysis that confirms the soundness of this theory? DR HETZER: Of course, there are many studies around describing the normal aortic valve, and I think it is well established that the noncoronary sinus usually is somewhat larger, next is the right coronary sinus, and the smallest is the left coronary sinus. Now, if this relationship is within a, let’s say, normal range, I think we would attempt such a procedure. If the noncoronary sinus or one of the sinuses is extremely large, we have not tried this procedure up to now. That means in this case we would do a valve-sparing operation or we would do a remodeling of the aortic root with external encasing of the root. But I must confess that we have only started to, let’s say, bring aortic valve repair to an art, and I think from this experience probably we will go further.
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Ann Thorac Surg 2012;94:1989
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0003-4975/$36.00
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1989
Ann Thorac Surg 2012;94:1983–9
Background. Ascending aortic aneurysms grow circumferentially and longitudinally. This geometric dislocation with widening, flattening, or loss of the sinotubular junction by aortic dilatation distorts and causes incompetence of even a structurally normal valve. We described a technique of surgical correction of ascending aortic aneurysm and valve incompetence by relocating the displaced aortic annulus plane to its normal anatomic position. Methods. Between 1998 and 2011, 48 patients (median age, 66.5; range, 7 to 82 years) with ascending aortic aneurysm and elongation and severe aortic valve incompetence underwent ascending aortic replacement. The aneurysm was incised longitudinally, and an appropriately sized straight Dacron (DuPont, Wilmington, DE) graft was sutured onto the aorta approximately 5 mm above the commissures, recreating the sinotubular junction. When valve competence was assured, the graft, cut considerably shorter than the original length of the
ascending aorta, was anastomosed distally. The valve plane was hence relocated in a more cranial/oblique position, restoring its normal alignment. Perioperative echocardiographic and computed tomography studies were done to document the degree of aortic valve incompetence and the morphology of the aortic root. Results. During a mean follow-up of 3.0 ⴞ 2.7 years, aortic insufficiency was absent to trivial in 34, mild in 12, and moderate in 2 patients. Postoperative computed tomography showed considerable aortic shortening, remarkable sinotubular junction narrowing, aortic root diameter reduction, and angular widening between the aortic root plane and longitudinal spinal axis corresponding to aortic incompetence reduction. Conclusions. Aortic relocation technique provided satisfactory results in management of ascending aortic aneurysm and elongation with aortic valve incompetence. (Ann Thorac Surg 2012;94:1983–9) © 2012 by The Society of Thoracic Surgeons
S
Understanding the pathophysiology of aortic root aneurysm and morphology of the aortic valve in this disease entity, precise knowledge of the anatomic and geometric relationships among the various components of the aortic root, and a thorough understanding of the mechanism of valve incompetence in this setting is indispensable and the key to a satisfactory outcome of an aortic valve– sparing operation. Ascending aortic aneurysms grow circumferentially and longitudinally. Longitudinal growth affects the ascending aorta asymmetrically, being more conspicuous on the right side, hence shifting the valve annulus plane from its original oblique position relative to the longitudinal body axis into a more parallel position [10, 11] (Fig 1A). This geometric dislocation distorts the valve and may cause prolapse of the noncoronary cusp and incompetence of a structurally normal valve. Widening, flattening, or loss of the sinotubular junction by aortic dilatation may further add to impaired leaflet coaptation. This report describes a technique of surgical correction of ascending aortic aneurysm and aortic valve incompetence by relocating the displaced aortic valve annulus
ince the introduction of aortic remodeling technique by Fagan and colleagues [1] in 1982 and the reimplantation technique by David and Feindel [2] in 1992, aortic valve-sparing operations to treat patients with aortic root pathologies have gained interest. Both surgical strategies support the wall of the aortic root to different magnitudes. Various modifications of the techniques initiated by Yacoub and David to improve functional characteristics of the aortic valve have evolved [3– 8], which have been theoretically appealing, with excellent early results. A longer-term follow-up, especially of aortic valve function over time, is mandatory to assess these different methods [9]. At present, none of these procedures has been able to meet the complexity of aortic root and valve function in its entirety, rendering the durability of the repair questionable.
Accepted for publication July 16, 2012. Presented at the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25–27, 2010. Address correspondence to Dr Delmo Walter, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
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Surgical Correction of Ascending Aortic Aneurysm and Aortic Valve Incompetence by Relocation of the Aortic Valve Plane Using a Short Aortic Replacement Graft
1984
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Ann Thorac Surg 2012;94:1983–9
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Fig 1. (A) Graphic representation of the mechanism of asymmetric aneurysmal growth of the ascending aorta, with shift of the aortic root towards the left to a position parallel to the vertebral column. (B) Replacing the aneurysmal ascending root with a short graft, relocating the aortic valve plane upwards, and recreating the sinotubular junction. Measured computerized tomography scan dimensions are: A, distance between the deepest point of noncoronary sinus and right inferior rim of the take-off of the brachiocephalic trunk; B, distance between the left coronary ostium and the left inferior rim of the take-off of left subclavian artery; C, diameter of presumed new sinotubular junction; D, diameter of aortic root at level of coronary ostia; and E, angle between coronary ostial plane and sagittal spine plane.
plane to its normal anatomic position. This is achieved by replacement of the ascending aorta with a vascular graft considerably shorter than the original aortic length, with a graft diameter that equals the size of the inner valve annulus, hence recreating a supravalvular narrowing at the site of the sinotubular junction.
Patients and Methods The Institutional Review Board approved this study and patient consent was obtained for the planned surgical strategy of aortic valve preservation and possible valve replacement.
Patients Between November 1998 and September 2011, 48 patients (male/female ratio, 1:1), with ascending aortic aneurysm, elongation, and variable degree of incompetence of a structurally normal aortic valve (grade I-IV), underwent ascending aortic replacement. Patients were a mean age of 62.5 years (median, 66.5; range, 7 to 82 years). The study excluded 11 patients (10 men; mean age, 57.09; range, 46 to 65 years). In 5 patients, intraoperative assessment of aortic valve competence after the procedure demonstrated persistence of insufficiency; hence, a decision to replace the aorta with a valved conduit was made. In the other 6 patients, intraoperative inspection of the aortic valve showed aneurysm of the sinus of Valsalva in 2 patients and annular dilatation with calcified right coronary leaflet, annular dilation and severely thinnedout aortic root, prolapse of left coronary leaflet, and calcified left and noncoronary leaflet with prolapse in 1 patient each. The planned aortic relocation was not even attempted in these patients, but straightforward ascending aortic root and valve replacement was done. Preoperative echocardiographic and computed tomography (CT) studies were done. CT (Siemens Somatom Definition machine, Munich, Germany) data were recon-
structed and analyzed using 3-dimensional (3D), Inspace and circulation postprocessing tools (Siemens Leonardo Workstation). Volume-rendering technique was used for spatial measurements and dynamic reconstructions; 3D and circulation tools were used for morphologic, anatomic, and functional assessment of the aortic valve and ascending aorta. Figure 1B shows the CT scan-measured dimensions we were interested in: A is the distance between the deepest point of noncoronary sinus and right inferior rim of the take-off of the brachiocephalic trunk; B is the distance between left coronary ostium and the left inferior rim of the take-off of the left subclavian artery; C is the diameter of the presumed new sinotubular junction; D is the diameter of aortic root at level of coronary ostia; and E is the angle between coronary ostial plane and sagittal spine plane.
Surgical Technique The operation was performed through a median sternotomy under total cardiopulmonary bypass except in 3 patients with concomitant aortic arch replacement, in whom deep hypothermia (16°C), low flow perfusion through the femoral artery, and selective cerebral perfusion through the brachiocephalic trunk were used. In patients with isolated ascending aortic aneurysms, the aortic arch and the right atrium were cannulated with a left ventricular vent catheter introduced through the right upper pulmonary vein. Except in patients with concomitant arch replacement, the ascending aorta was clamped just below the take-off of the brachiocephalic trunk. The ascending aortic root aneurysm was incised longitudinally directed toward the noncoronary sinus to a point halfway between the cranial tips of the neighboring commissures. The sinuses were inspected beforehand, taking note of the symmetry of dilatation. In this series, all 3 coronary sinuses were dilated symmetrically in 13 patients, the noncoronary sinus was most dilated in
HETZER ET AL SHORT GRAFT FOR AORTIC VALVE PLANE RELOCATION
28, the left coronary sinus was most dilated in 5, and the right coronary sinus was most dilated in 2. Blood cardioplegia, infused directly through the coronary ostia, repeated every 20 minutes, was used for myocardial protection. The aortic valve was carefully inspected and tested for competence. A decision to preserve the valve was made when the valve was found to be structurally normal with good leaflet coaptation. The inner diameter of the valve annulus was measured to choose a straight Dacron (DuPont, Wilmington, DE) vascular graft that matched the measured inner diameter. Then this graft was proximally anastomosed to the aorta approximately 5 mm above the commissures using a continuous suture of polypropylene 4-0. The competence of the aortic valve was tested by infusing blood cardioplegic solution into the graft under pressure and by pulling the aortic valve annulus toward the arch. When aortic valve competence was assured, the graft was cut to a length considerably shorter than the original aortic length and to a degree that maintained the aortic valve competence under pressured cardioplegia infusion. The distal aortic anastomosis was performed using continuous suture with a polypropylene 4-0. The graft inclusion technique, with wrapping of the aneurysmal wall around the implanted graft, was used in all patients. Intraoperative transesophageal echocardiography (Fig 2) was used routinely to assess and document the aortic valve competence and the morphology of the aortic root before and after the procedure.
Follow-Up
1985
All patients were prospectively monitored. Serial echocardiographic studies to assess aortic valve competence were done throughout the follow-up period. The CT scan variables (see “Patients” and Fig 1B) were measured postoperatively and at the latest follow-up.
Statistical Analysis Discrete data are expressed as absolute and percentage frequency values and continuous data as mean ⫾ standard deviation or median and range, as appropriate. Repeated measurements of echocardiographic variables, including aortic valve area (cm2), annulus size (cm), and leaflet area (cm) in serial timelines, were analyzed with Friedman tests. Mann-Whitney U test was used to facilitate comparison between preoperative and follow-up CT scan dimensions. A p value of 0.05 or less was considered significant. Freedom from reoperation and cumulative survival rates were analyzed according to Kaplan-Meier estimates with the 95% confidence interval (CI). All data were analyzed with SPSS 16.0 software (SPSS Inc, Chicago IL).
Results Postoperative Course No postoperative morbidity or 30-day hospital deaths occurred. Late deaths included a patient who died of ruptured descending aortic aneurysm at 42 days and a Fig 2. (A) Intraoperative transesophageal echocardiogram before the relocation procedure shows extensive ascending aortic aneurysm, loss of the sinotubular junction and normal valve leaflets. (B) The Doppler studies show massive aortic incompetence. Imaging after relocation shows (C) new sinotubular narrowing at the proximal anastomosis of the graft and (D) a very competent aortic valve.
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patient who died of pneumonia at 66 days. At 12 years after the initial aortic root replacement, a patient underwent reoperation for progression of an aortic arch aneurysm and died 40 days after the second operation.
Since this initial successful case with favorable longterm results, the technique has been used in a consecutive series of 48 patients with ascending aortic aneurysm with aortic valve incompetence. Hence, we recognized that restoration of orientation and location of the aortic valve plane restores the geometry of the sinotubular junction, which is often flattened by the aneurysm. This distortion thus causes leaflet prolapse, leading to impaired leaflet coaptation. We believe that restoration of a supravalvular narrowing at the site of the sinotubular junction is important in maintaining valve competence. Relocating the width of the aortic root at the widest extension of the sinuses by a shorter graft reengineers the normal alignment of the valve relative to the aortic root. This aortic valve relocation technique and the mechanism of restoration of valve competence in ascending aortic root aneurysm was first mentioned in a review article in 2007 [10] and presented at the Forty-sixth Annual Meeting of the Society of Thoracic Surgeons in January 2010 [11]. In aortic root aneurysm, isolated dilation of the aortic sinuses does not cause aortic valve incompetence [20]. However, it alters the anatomic relationships of the various components of the aortic root, which is why patients with aortic root aneurysms may have entirely competent aortic valves. As the sinotubular junction or aortic annulus, or both, dilate, the coaptation area of the cusps decreases, and valve incompetence ensues. Dilatation of these structures increases the mechanical stress on the aortic cusps, which thin and stretch, leading to development of stress fenestrations along the commissures. Depending on the extent and degree of damage, the aortic cusps may be beyond salvage. Likewise, lengthening and distortion of the aortic base may cause prolapse of mainly the noncoronary leaflet, of which the mechanism is similar to aortic incompetence in acute type A dissection, when the inner layer of the aorta bearing one or two of the aortic valve commissures (usually the ones near the noncoronary cusp) shifts down toward the left ventricular cavity. In this context, valve competence can be restored by suspension of the aortic valve during the ascending aorta replacement. In chronic aortic root aneurysm, it is not only the restoration of the location and orientation of the valve that is of utmost importance; rather, the restoration of a sinotubular junction must also be considered. The aortic narrowing at the sinotubular junction, just beyond the commissures, is necessary for good leaflet coaptation and valve closure. This concept was recognized by Leonardo da Vinci [12] and several modern investigators [24 –26].
Follow-Up During a mean follow-up of 3.0 ⫾ 2.7 years (median, 2.3 years; range, 11 months to 12.2 years; 1,487 patient-years), aortic valve incompetence was absent to trivial in 34 patients, mild in 12, and moderate in 2. Table 1 reports the preoperative and postoperative aortic dimensions measured by CT scan. Remarkably significant postoperative changes (p ⬍ 0.001) occurred in all measured CT variables as follows: A, ⫺20.3% ⫾ 8.9%; B, ⫺14.3% ⫾ 6.5% (both A and B show that there is a considerable shortening of the aorta); C, ⫺40.8% ⫾ 9.0% (sinotubular junction became smaller); D, ⫺14.9% ⫾ 9.3% (diameter of the aortic root is significantly smaller); and E, ⫹52.0% ⫾ 40.5% (angle between the aortic root plane and longitudinal axis of the spine became wider, which corresponds to reduction of aortic incompetence (AI ⌬ mean, 1.9; Fig 3A and B). The present freedom from reoperation is 100% and cumulative survival is 93.7%.
Comment To this date, several authors have contributed much to the knowledge of aortic root function and the sinotubular junction, including Da Vinci [12] (1513), Corrigan [13] (1832), Reid [14] (1970), Bellhouse [15] (1973), Frater [16] (1986), Thubrikar [17] (1981), Robicsek [13] (1991), Kunzelman [18] (1994), David [19] (1995), and Furukawa [20] (1999). The surgical technique that has gained much popularity is that of David’s aortic valve–sparing operations, which have evolved from the accumulated knowledge of anatomy, physiology, pathology, and surgical experience [21–24]. In 1998, while operating on a patient with an ascending aortic aneurysm and aortic valve incompetence, on which an ascending aortic root and valve replacement was initially planned, an entirely normal aortic valve with tender, mobile, and well-coaptating leaflets was found. We searched for the cause of valve dysfunction, and in so doing, recognized that the valve became competent by elevating it at its noncoronary sinus. We thus opted for a supracoronary ascending aortic replacement with a graft shorter than the original length of the ascending aorta, which at the same time restored the valve competence. The technique was then termed aortic valve relocation.
Table 1. Perioperative Aortic Root Dimensions Based on Computed Tomography Scan Measurements Dimension A. Distance between noncoronary sinus and rim of brachiocephalic trunk B. Distance between left coronary ostium and rim of left subclavian artery C. Diameter of sinotubular junction D. Diameter of the aortic root at coronary ostia E. Angle between coronary ostial plane and sagittal spine plane
Preoperative (mm)
Postoperative (mm)
120.5 ⫾ 12.8 102.2 ⫾ 13.2 45.4 ⫾ 7.6 41.9 ⫾ 5.9 45.5 ⫾ 10.01
95.4 ⫾ 12.1 87.2 ⫾ 11.9 26.3 ⫾ 2.4 35.2 ⫾ 4.1 65.5 ⫾ 12.0
% Change –20.3 ⫾ 8.9 ⫺14.3 ⫾ 6.5 ⫺40.8 ⫾ 9 ⫺14.9 ⫾ 9.3 52.0 ⫾ 40.5
Fig 3. Four-dimensional computed tomography scan reconstructions show the aortic annular angle (A) before and (B) after the aortic relocation procedure.
Ascending aortic aneurysm causes aortic valve insufficiency because of the dilatation of the sinotubular junction, which pulls the cusps apart and hinders central coaptation. These cusps usually remain normal, although occasionally the free margins of one or more cusps become elongated because of the increased stress caused by the dilation of the sinotubular junction. The significance of sinotubular junction in aortic valve closure has been acknowledged by many authors [15, 27–29] since Leonardo da Vinci’s postulate that its presence, by creating eddy currents and a small pressure
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1987
gradient across the aortic and ventricular aspects of the leaflets, contributes to smooth and coordinated valve closure. Robicsek [30] and Makhijani and colleagues [31], as well as Thubrikar and colleagues [32], confirmed in their series of experimental studies the beneficial effects of the sinuses of Valsalva on aortic valve dynamics. That the functional unit of the semilunar valve is not the leaflets alone but includes the leaflets’ commissural suspension and its corresponding sinus as well was demonstrated by Robicsek and Thubrikar [33] in their wellcontrolled experiments. They found that the presence of 3 compliant sinuses assures a physiologic systolic expansion and diastolic shortening of the diameter of the normal aortic root, generating a “pull-and-release” commissural function that contributes to a smooth, gradual, and symmetrical opening of the leaflets during systole and synchronous coordinated leaflet approximation during diastole. Although the aortic root still maintains the basic hemodynamics in pressure-flow relations and valve competence, the modulated function of the sinotubular junction and sinuses, which is perfect in the normal aortic root, is greatly disturbed in aortic root aneurysm, hence contributing significantly to the valve incompetence. In our aortic valve relocation technique, we ensure that the width of the sinotubular junction must equal the diameter of the prosthetic vascular graft, the appropriate size of which is measured intraoperatively to match the inner diameter of the aortic valve annulus. Relocating the aortic valve to its normal anatomic position and orientation relative to the aortic root by implanting a graft considerably shorter than the original length of the ascending aorta completely restored its competence in these 48 patients with supracoronary ascending aneurysm, elongation of the aorta, and aortic valve incompetence in an entirely structurally normal valve. The absence of reoperation during the midterm and long-term follow-up shows that relocation provides effective and long-lasting functional valve competence and obviates the need for complicated valve repair procedures or even valve replacement. In conclusion, ascending aortic aneurysm and elongation with incompetence of the aortic valve can be successfully treated by replacement with a short graft, relocating the valve plane to its normal position and alignment, as shown by the angle between the aortic valve plane and the spine, and recreating the sinotubular junction, hence restoring the competence of a normally structured aortic valve. We have shown that restoration of the supravalvular narrowing at the sinotubular junction is precisely important for valve competence. Likewise, we have shown that the effect of restoring and relocating the width of the aortic root at the widest extension of the sinuses is an effective remodelling process. This technique has been promising in Marfanrelated annuloaortic ectasia or even in bicuspid valves, of which clinical studies are currently being done in our institution.
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We greatly appreciate the assistance of Christine Detschades, Julia Stein, and Astrid Benhennour, and thank Anne Gale for editing the manuscript. ADULT CARDIAC
References 1. Fagan A, Yacoub MH, Pillai R, Radley-Smith R. Dacron replacement of the ascending aorta and sinuses with resuspension of the aortic valve and reimplantation of the coronary arteries: a new method for treatment of aneurysmal or acute dissection of the aortic root. Proceedings of the Joint International Cardiovascular and Thoracic Surgical Conference, Stockholm (abstract). Scand J Cardiothorac Surg 1982; 16:175. 2. David TE, Feindel CM. An aortic valve-sparing operations for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617–21. 3. Sarsam MA, Yacoub M. Remodeling of the aortic valve annulus. J Thorac Cardiovasc Surg 1993;105:435– 8. 4. Miller DC. Valve-sparing aortic root replacement in patients with Marfan’s syndrome. J Thorac Cardiovasc Surg 2003;125: 773– 8. 5. Erasmi A, Sievers HH, Scharfshwerdt M, Eckel T, Misfeld M. In vitro hydrodynamics, cusp-bending deformation, and root distensibility for different types of aortic valve-sparing operations: remodeling, sinus prosthesis, and reimplantation. J Thorac Cardiovasc Surg 2005;130:1044 –9. 6. Hetzer R, Komoda T, Komoda S, Berger F, Huebler M. New aortic root remodeling surgery in aortic root aneurysm. Ann Thorac Surg 2010;89:1260 – 4. 7. De Paulis R, De Mattheis GM, Nardi P, Scaffa R, Buratta MM, Chiariello L. Opening and closing characteristics of the aortic valve after valve-sparing procedures using a new aortic root conduit. Ann Thorac Surg 2001;72:487–94. 8. Hetzer R, Komoda S, Komoda T. Remodeling of aortic root by annular reconstruction and plication of sinuses of Valsalva. J Card Surg 2008;23:49 –51. 9. Akins CW, Miller DC, Turina MI, et al. Guidelines for reporting mortality and morbidity after cardiac valve interventions. Ann Thorac Surg 2008;85:1490 –5. 10. Hetzer R, Pasic M, Eichstädt H. Chirurgie des aorta ascendens und des Aortenbogens. Herzmedizin 2007;4:175– 82. 11. Hetzer R, Solowjowa N, Kukucka M, Knosalla C, Röttgen R. Correction of aortic valve competence combined with ascending aortic aneurysm by relocation of the aortic valve plane through a short-length aorti-graft replacement. In: Yankah, CA, Weng Y, Hetzer R, editors. Aortic root surgery: the biological solution. Berlin Heidelberg New York: Springer Verlag; 2010:177– 84. 12. Keele KD, Pedretti C, eds. Leonardo da vinci. Corpus of the anatomical sudies in the collection of her majesty, the queen, at Windsor Castle. London, New York: Johnson reprint, Harcourt Brace Jovanovich; 1978 –1980. 13. Robicsek F. Leonardo da Vinci and the sinuses of Valsalva. Ann Thorac Surg 1991;52:328 –35. 14. Reid K. The anatomy of the sinus of Valsalva. Thorax 1970;25:79 – 85.
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15. Bellhouse BJ, Bellhouse F, Abbott JA, Talbot L. Mechanism of valvular incompetence in aortic sinus dilatation. Cardiovasc Res 1973;7:490 – 4. 16. Frater RW. Aortic valve insufficiency due to aortic dilatation: correction by sinus rim adjustment. Circulation 1986;74: I136 – 42. 17. Thubrikar M, Piepgrass WC, Shaner TW, Nolan SP. The design of the normal aortic valve. Am J Physiol 1981;241: H795– 801. 18. Kunzelman KS, Grande KJ, David TE, Cochran RP, Verrier ED. Aortic root and valve relationships. Impact on surgical repair. J Thorac Cardiovasc Surg 1994;107:162–70. 19. David TE, Feindel CM, Bos J. Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm.J Thorac Cardiovasc Surg 1995;109:345–51; discussion 351–2. 20. Furukawa K, Ohteki H, Cao ZL, et al. Does dilatation of the sinotubular junction cause aortic regurgitation? Ann Thorac Surg 1999;68:949 –53; discussion 953– 4. 21. David TE. Surgical treatment of ascending aorta and aortic root aneurysms. Prog Cardiovasc Dis 2010;52:438 – 44. 22. David TE, Maganti M, Armstrong S. Aortic root aneurysm: principles of repair and long-term follow-up. J Thorac Cardiovasc Surg 2010;140:S14 –9. 23. David TE. How I do aortic valve sparing operations to treat aortic root aneurysm. J Card Surg 2011;26:92–9. 24. Grande-Allen KJ, Cochran RP, Reinhall PG, Kunzelmann KS. Re-creation of sinuses is imprtant for sparing the aortic valve: a finite element study. J Thorac Cardiovasc Surg 2000;119:753– 63. 25. Zehr KJ, Thubrikar MJ, Gong GG, Headrick JR, Robicsek F. Clinical introduction of a novel prosthesis for valvepreserving aortic root reconstruction for annuloaortic ectasia. J Thorac Cardiovasc Surg 2000;120:692– 8. 26. Demer P, Miller DC. Simple modification of “T. David-V” valve sparing aortic root replacement to create graft pseudosinuses. Ann Thorac surg 2004;78:1479 – 81. 27. Peskin CS, Wolfe AW. The aortic sinus vortex. Fed Proc 1978;37:2784 –92. 28. Von Steenhoven AA, Verlaan CWJ, Veenstra PC, Reneman RS. In vivo cinematographic analysis of the behavior of the aortic valve. Am J Physiol 1981;240:H286 –92. 29. Henderson Y, Johnson FE. Two modes of closure of heart valves. Heart 1912;4:69 – 82. 30. Robicsek F. Leonardo da Vinci’s anatomical drawings. In: Grossi A, Donatelli F, Como A, Brodman R, eds. Cardiology and cardiac surgery: current topics. Mount Kisco, NY: Futura Publishing Co Inc; 1992:3–29. 31. Makhijani V, Yang HQ, Donne PJ, Thubrikar MJ. Threedimensional coupled fluid-structure simulation of pericardial bioprosthetic aortic valve function. ASIAO J 1997;43: M387–92. 32. Thubrikar MJ, Robicsek F, Beck A. Stress analysis of the aortic valve with and without the sinuses of Valsalva. Presented at: World Symposium on Heart Valve Disease, London, June 1999:248. 33. Robicsek F, Thubrikar MJ. Role of sinus wall compliance in aortic leaflet function. Am J Cardiol 199;84:944 – 46.
DISCUSSION DR JOHN S. IKONOMIDIS (Charleston, SC): Dr Hetzer, this patient population is obviously a small number from a much larger patient population. Can you give us some insights into what the preoperative assessments were that made you confident that you would be able to achieve competence of the aortic valve just with sinotubular junction remodeling alone and relocation of the valve? I ask because, looking at the case that you presented, I might have been inclined to do a valve-sparing
root replacement on that patient rather than just sinotubular junction remodeling. DR HETZER: Pardon me? DR IKONOMIDIS: The patient that you presented, looked to me like a good candidate for a valve-sparing root replacement as opposed to a supracoronary graft, but you clearly achieved
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success with the supracoronary graft. Could you tell us a little bit about how you assess these patients for that procedure?
junction leaflets are the most significant factors. It may well be that the sinotubular junction ridge really plays a major role.
DR HETZER: Of course. We have a fairly large aortic program with roughly 400 to 500 cases per year, and this is very small selection. As you have seen, I did this one case 11 years ago, and then I sort of forgot about it. It came up again when this combination of ascending aortic aneurysm and incompetent valve was presented, and the echocardiographer told me that the valve was entirely normal. That means the valve leaflets were entirely normal, and it is true, the patient had like grade II or III aortic incompetence. And then I said, okay, let’s have a look at it, and when opening the aortic aneurysm, we then saw that the valve was entirely normal. And by just trying to move the base around, it became clear that by just lifting it up, the leaflets would coapt. As I said, this is a very selected subset of cases here, because we wanted to make sure that we didn’t have any failures and significant incompetence afterwards. There were cases where we changed during the operation when we saw, doing the initial testing, that the significant incompetence was present. I think we have to further study those cases. And as I said in the end, we are not quite sure yet whether the elongation, the displacement, or the sinotubular
DR R. SCOTT MITCHELL (Stanford, CA): Continuing that investigation, are there echocardiographic features, say specifically, asymmetric sinus enlargement, that you can determine and that correlates, and to follow that, postoperative echocardiographic or computed tomography analysis that confirms the soundness of this theory? DR HETZER: Of course, there are many studies around describing the normal aortic valve, and I think it is well established that the noncoronary sinus usually is somewhat larger, next is the right coronary sinus, and the smallest is the left coronary sinus. Now, if this relationship is within a, let’s say, normal range, I think we would attempt such a procedure. If the noncoronary sinus or one of the sinuses is extremely large, we have not tried this procedure up to now. That means in this case we would do a valve-sparing operation or we would do a remodeling of the aortic root with external encasing of the root. But I must confess that we have only started to, let’s say, bring aortic valve repair to an art, and I think from this experience probably we will go further.
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Ann Thorac Surg 2012;94:1983–9