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Technique of aortic valve replacement
Technique of aortic valve replacement A technique of prosthetic aortic valve insertion which uses through-and-through mattress sutures tied outside the aorta is described. This technique is particularly useful whenever the valve annulus is friable following removal of the calcium of a heavily calcified aortic valve.
R. E . Girardet, M . D . , and M . W . Wheat, J r . , M . D . , Largo,
A he technique reported here was developed* as an answer to the problem of periprosthetic leakage following aortic valve replacement.1 The principle of the technique consists of using horizontal mattress sutures tied outside the aortic wall over felt bolsters (either Teflon or Dacron) to hold the prosthesis securely in place. These sutures take a horizontal purchase on the entire thickness of the aortic wall and give a strong prosthetic approximation to the aortic wall. Thus the risk of periprosthetic leakage is essentially eliminated. Method Aortic valve replacement is performed with total cardiopulmonary bypass and moderate hypothermia to 30° C. Intermittent perfusion of both coronary arteries for 5 of every 20 minutes of ischemic arrest is the preferred method of myocardial protection. The following description and the figures are oriented from the position of the surgeon at the right side of the operating table. The ascending aorta is cross-clamped with a nontraumatic clamp,t and a hockey-stick aortotomy, curved proximally into the noncoronary sinus, is made (Fig. 1, A). In preparation for placement of the mattress sutures to be tied outside the aortic wall and deep at the level of the prosthetic sewing skirt, the aortic root (defined as that portion of ascending aorta Received for publication July 2, 1975. Address for reprints: Myron W. Wheat, Jr., M.D., Department of Surgery, Diagnostic Clinic, 1551 West Bay Drive, Largo, Fla. 33540. *Dr. Laurence K. Groves and others at the Cleveland Clinic were using horizontal mattress sutures tied over Teflon felt bolsters along the noncoronary side of their aortic valve replacements in the early 1960's. tFogarty Hydrogrip clamp, Model No. 624, Edwards Laboratories, Inc., Santa Ana, Calif.
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Fla.
comprised between the aortic annulus fibrosus to 2 cm. superior to the coronary artery ostia2) is circumferentially dissected, except under the coronary arteries. This dissection is first carried out opposite the right and left coronary sinuses, between the aortic root on one side and the main pulmonary artery and the right ventricular outflow tract on the other side. The first assistant maintains exposure by retracting the pulmonary artery and the right ventricle to the left and inferiorly while the surgeon dissects close to the aortic root (Fig. 1, B). The dissection proceeds toward the aortic annulus until a plane is reached on the outside of the aorta, which corresponds to the site of the aortic cusp attachments on the inside of the aortic wall. Posteriorly, the dissection is conducted as close as possible to the left coronary artery. Anteriorly, the dissection proceeds to, and often slightly under, the right coronary artery (Fig. 1, B). With the assistant now retracting the aorta and the right atrial wall, the surgeon then dissects the aortic root opposite the noncoronary sinus, going again proximally to the level of the valve insertion and laterally as close as possible to both coronary arteries (Fig. 1, C). These initial steps of the operation result in exposure of the outside of the aortic root except for two small segments situated directly under the coronary artery orifices (Fig. 1, D). So that trauma to the aortic wall will be minimized, the aorta is handled and retracted only with packing forceps (smooth, no teeth). The diseased valve cusps and the calcium on the aortic wall and anterior mitral leaf are removed by sharp dissection and careful teasing away of calcium fragments until as smooth and large an annulus as possible is achieved. The proper-sized valve is selected. In this description, the Bjork-Shiley prosthesis (Shiley Laboratories, Inc, Santa Ana, Calif.), which is our prosthesis of choice, is depicted. The prosthesis is oriented to have the disc open toward the
Volume 71 Number 3 March, 1976
Aortic valve replacement
Fig. 1. Fig. 3.
Fig. 2.
Fig. 4.
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The Journal of Thoracic and Cardiovascular Surgery
4 4 8 Girardet and Wheat
Fig. 5. noncoronary sinus. During placement of the sutures, the prosthesis is held by the special holder provided by the manufacturer or else with Allis forceps attached to the skirt, but for simplicity the holders have been omitted from the drawings. Sutures of 2-0 Ethiflex (Ethicon, Inc., Sommerville, N. J.) are used throughout. Sutures are placed first in the two segments of aortic root which underlie the coronary orifices and usually have not been dissected externally. These simple over-and-over sutures are placed and tied later inside the lumen of the aorta. The prosthesis is held toward the right coronary artery, and single-armed sutures are passed through the sewing ring of the prosthesis and into the aorta, under the left coronary artery (Fig. 2, A). Whether the sutures are placed in the cusp remnant alone or a little deeper within the aortic wall depends on the texture of the cusp remnant (Fig. 2, B). In this area, care must be taken to avoid including any of the wall of the sinus of Valsalva. When tied, sutures extending superiorly into the sinus of Valsalva produce linear tears that can be very troublesome. Four to six sutures are used. Their needles are cut and the ends of the sutures are held together in a small clamp (Fig. 2, C). The prosthesis is then held toward the left coronary artery. Similar
Fig. 7. sutures are passed through the appropriate segment of prosthetic sewing ring and then inserted under the right coronary artery. Again, this area corresponds to the nondissected portion of aortic root which lies under the right coronary artery orifice (Fig. 3, A). Two to four sutures are necessary. Their needles are cut and the suture ends held in another small clamp (Fig. 3, B). All remaining sutures are of the mattress type. They are passed horizontally through the aortic wall and are destined to be tied outside the aorta over felt bolsters. The segment of aortic root centered on the commissure between the left and right valve cusps and extending
Volume 71 Number 3 March, 1976
laterally toward the left and right coronary arteries is sutured first. The prosthesis is held toward the noncoronary sinus. Double-armed sutures are passed through the prosthetic sewing ring and then through the aortic wall, inside at the level of the cusp attachment on the aorta (Fig. 4, A). This level corresponds to the deepest point of dissection outside the aortic root (Fig. 4, B). The first and last mattress sutures are placed close to and sometimes overlapping (Fig. 1, B) the single sutures already inserted under each coronary artery. Four to seven mattress sutures are necessary to suture this segment of aortic root. The distance on the aorta between the two arms of a horizontal mattress suture should not be more than 2 to 3 mm. This minimizes the risk of creating a linear tear on the aortic wall when the suture is tied or a pucker which can produce a perivalvular leak. The prosthesis is then lowered into place, the handle used until now to hold the prosthesis is removed, and a single one of the sutures already inserted under the coronary arteries is tied under each coronary artery (Fig. 4, C). At mid-distance between those two last sutures, and on the noncoronary sinus side of the aortic root, one mattress suture is passed through the prosthetic sewing ring and through the aortic wall at the level of attachment of the noncoronary valve cusp (Fig. 5, A). This suture is tied outside the aorta over a felt bolster (Fig. 5, B and 5, C). The prosthesis is now held in its final or seated position by three almost equidistant fixation points. This sequential detail is important because, with the prosthesis so stabilized, the remaining mattress sutures can be accurately inserted at the proper level along the noncoronary segment of aortic root. Ten to fifteen mattress sutures are needed, the first and last mattress sutures again being inserted close to the single sutures already in place under the coronary
Aortic valve replacement
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arteries (Fig. 6, A). Once all sutures have been inserted, the single sutures under the coronary arteries are tied inside the aorta and cut, and the mattress sutures are tied outside the aorta over Dacron or Teflon felt bolsters and cut (Fig. 6, B). The aortotomy is closed in two layers (Fig. 7). The first layer is made by a few horizontal mattress sutures of 3-0 Ethiflex tied over felt bolsters. The second layer is made by a continuous over-and-over suture of 4-0 Tevdek. Air is removed from the ascending aorta prior to completion of the aortic closure. The remaining portions of the operation are routine. Discussion Since first outlined,1 this technique has been used with satisfaction by the senior author for all aortic valve replacements. With care and with attention particularly paid to preventing injury of the right coronary artery, the surgeon can safely dissect the aortic root with little additional time. This technique of aortic prosthesis insertion is particularly advantageous in patients having a heavily calcified valve and valve annulus, in whom the bed available for seating of the prosthesis is friable and contains little tough tissue suitable for holding sutures. Because the sutures are of the mattress type and are tied outside the aorta over felt bolsters for most of the valve circumference, solid fixation of the prosthesis can be achieved in all instances and the risk of periprosthetic leakage is eliminated. REFERENCES 1 Wheat, M. W., Jr., Linhart, J. W., Bartley, T. D., Taylor, W. J., Crevasse, L. E., and Green, J. R., Jr.: Aortic Ball-Valve (Starr-Edwards) Prosthesis: A Follow-up Evaluation, Ann. Thorac. Surg. 2: 166, 1966. 2 Wheat, M. W., Jr., and Bartley, T. D.: Aneurysms of the Aortic Root, Chest 47: 430, 1965.
R. E . Girardet, M . D . , and M . W . Wheat, J r . , M . D . , Largo,
A he technique reported here was developed* as an answer to the problem of periprosthetic leakage following aortic valve replacement.1 The principle of the technique consists of using horizontal mattress sutures tied outside the aortic wall over felt bolsters (either Teflon or Dacron) to hold the prosthesis securely in place. These sutures take a horizontal purchase on the entire thickness of the aortic wall and give a strong prosthetic approximation to the aortic wall. Thus the risk of periprosthetic leakage is essentially eliminated. Method Aortic valve replacement is performed with total cardiopulmonary bypass and moderate hypothermia to 30° C. Intermittent perfusion of both coronary arteries for 5 of every 20 minutes of ischemic arrest is the preferred method of myocardial protection. The following description and the figures are oriented from the position of the surgeon at the right side of the operating table. The ascending aorta is cross-clamped with a nontraumatic clamp,t and a hockey-stick aortotomy, curved proximally into the noncoronary sinus, is made (Fig. 1, A). In preparation for placement of the mattress sutures to be tied outside the aortic wall and deep at the level of the prosthetic sewing skirt, the aortic root (defined as that portion of ascending aorta Received for publication July 2, 1975. Address for reprints: Myron W. Wheat, Jr., M.D., Department of Surgery, Diagnostic Clinic, 1551 West Bay Drive, Largo, Fla. 33540. *Dr. Laurence K. Groves and others at the Cleveland Clinic were using horizontal mattress sutures tied over Teflon felt bolsters along the noncoronary side of their aortic valve replacements in the early 1960's. tFogarty Hydrogrip clamp, Model No. 624, Edwards Laboratories, Inc., Santa Ana, Calif.
446
Fla.
comprised between the aortic annulus fibrosus to 2 cm. superior to the coronary artery ostia2) is circumferentially dissected, except under the coronary arteries. This dissection is first carried out opposite the right and left coronary sinuses, between the aortic root on one side and the main pulmonary artery and the right ventricular outflow tract on the other side. The first assistant maintains exposure by retracting the pulmonary artery and the right ventricle to the left and inferiorly while the surgeon dissects close to the aortic root (Fig. 1, B). The dissection proceeds toward the aortic annulus until a plane is reached on the outside of the aorta, which corresponds to the site of the aortic cusp attachments on the inside of the aortic wall. Posteriorly, the dissection is conducted as close as possible to the left coronary artery. Anteriorly, the dissection proceeds to, and often slightly under, the right coronary artery (Fig. 1, B). With the assistant now retracting the aorta and the right atrial wall, the surgeon then dissects the aortic root opposite the noncoronary sinus, going again proximally to the level of the valve insertion and laterally as close as possible to both coronary arteries (Fig. 1, C). These initial steps of the operation result in exposure of the outside of the aortic root except for two small segments situated directly under the coronary artery orifices (Fig. 1, D). So that trauma to the aortic wall will be minimized, the aorta is handled and retracted only with packing forceps (smooth, no teeth). The diseased valve cusps and the calcium on the aortic wall and anterior mitral leaf are removed by sharp dissection and careful teasing away of calcium fragments until as smooth and large an annulus as possible is achieved. The proper-sized valve is selected. In this description, the Bjork-Shiley prosthesis (Shiley Laboratories, Inc, Santa Ana, Calif.), which is our prosthesis of choice, is depicted. The prosthesis is oriented to have the disc open toward the
Volume 71 Number 3 March, 1976
Aortic valve replacement
Fig. 1. Fig. 3.
Fig. 2.
Fig. 4.
AA1
The Journal of Thoracic and Cardiovascular Surgery
4 4 8 Girardet and Wheat
Fig. 5. noncoronary sinus. During placement of the sutures, the prosthesis is held by the special holder provided by the manufacturer or else with Allis forceps attached to the skirt, but for simplicity the holders have been omitted from the drawings. Sutures of 2-0 Ethiflex (Ethicon, Inc., Sommerville, N. J.) are used throughout. Sutures are placed first in the two segments of aortic root which underlie the coronary orifices and usually have not been dissected externally. These simple over-and-over sutures are placed and tied later inside the lumen of the aorta. The prosthesis is held toward the right coronary artery, and single-armed sutures are passed through the sewing ring of the prosthesis and into the aorta, under the left coronary artery (Fig. 2, A). Whether the sutures are placed in the cusp remnant alone or a little deeper within the aortic wall depends on the texture of the cusp remnant (Fig. 2, B). In this area, care must be taken to avoid including any of the wall of the sinus of Valsalva. When tied, sutures extending superiorly into the sinus of Valsalva produce linear tears that can be very troublesome. Four to six sutures are used. Their needles are cut and the ends of the sutures are held together in a small clamp (Fig. 2, C). The prosthesis is then held toward the left coronary artery. Similar
Fig. 7. sutures are passed through the appropriate segment of prosthetic sewing ring and then inserted under the right coronary artery. Again, this area corresponds to the nondissected portion of aortic root which lies under the right coronary artery orifice (Fig. 3, A). Two to four sutures are necessary. Their needles are cut and the suture ends held in another small clamp (Fig. 3, B). All remaining sutures are of the mattress type. They are passed horizontally through the aortic wall and are destined to be tied outside the aorta over felt bolsters. The segment of aortic root centered on the commissure between the left and right valve cusps and extending
Volume 71 Number 3 March, 1976
laterally toward the left and right coronary arteries is sutured first. The prosthesis is held toward the noncoronary sinus. Double-armed sutures are passed through the prosthetic sewing ring and then through the aortic wall, inside at the level of the cusp attachment on the aorta (Fig. 4, A). This level corresponds to the deepest point of dissection outside the aortic root (Fig. 4, B). The first and last mattress sutures are placed close to and sometimes overlapping (Fig. 1, B) the single sutures already inserted under each coronary artery. Four to seven mattress sutures are necessary to suture this segment of aortic root. The distance on the aorta between the two arms of a horizontal mattress suture should not be more than 2 to 3 mm. This minimizes the risk of creating a linear tear on the aortic wall when the suture is tied or a pucker which can produce a perivalvular leak. The prosthesis is then lowered into place, the handle used until now to hold the prosthesis is removed, and a single one of the sutures already inserted under the coronary arteries is tied under each coronary artery (Fig. 4, C). At mid-distance between those two last sutures, and on the noncoronary sinus side of the aortic root, one mattress suture is passed through the prosthetic sewing ring and through the aortic wall at the level of attachment of the noncoronary valve cusp (Fig. 5, A). This suture is tied outside the aorta over a felt bolster (Fig. 5, B and 5, C). The prosthesis is now held in its final or seated position by three almost equidistant fixation points. This sequential detail is important because, with the prosthesis so stabilized, the remaining mattress sutures can be accurately inserted at the proper level along the noncoronary segment of aortic root. Ten to fifteen mattress sutures are needed, the first and last mattress sutures again being inserted close to the single sutures already in place under the coronary
Aortic valve replacement
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arteries (Fig. 6, A). Once all sutures have been inserted, the single sutures under the coronary arteries are tied inside the aorta and cut, and the mattress sutures are tied outside the aorta over Dacron or Teflon felt bolsters and cut (Fig. 6, B). The aortotomy is closed in two layers (Fig. 7). The first layer is made by a few horizontal mattress sutures of 3-0 Ethiflex tied over felt bolsters. The second layer is made by a continuous over-and-over suture of 4-0 Tevdek. Air is removed from the ascending aorta prior to completion of the aortic closure. The remaining portions of the operation are routine. Discussion Since first outlined,1 this technique has been used with satisfaction by the senior author for all aortic valve replacements. With care and with attention particularly paid to preventing injury of the right coronary artery, the surgeon can safely dissect the aortic root with little additional time. This technique of aortic prosthesis insertion is particularly advantageous in patients having a heavily calcified valve and valve annulus, in whom the bed available for seating of the prosthesis is friable and contains little tough tissue suitable for holding sutures. Because the sutures are of the mattress type and are tied outside the aorta over felt bolsters for most of the valve circumference, solid fixation of the prosthesis can be achieved in all instances and the risk of periprosthetic leakage is eliminated. REFERENCES 1 Wheat, M. W., Jr., Linhart, J. W., Bartley, T. D., Taylor, W. J., Crevasse, L. E., and Green, J. R., Jr.: Aortic Ball-Valve (Starr-Edwards) Prosthesis: A Follow-up Evaluation, Ann. Thorac. Surg. 2: 166, 1966. 2 Wheat, M. W., Jr., and Bartley, T. D.: Aneurysms of the Aortic Root, Chest 47: 430, 1965.