© 2015 Wiley Periodicals, Inc.
448
SURGICAL TECHNIQUE ___________________________________________________________
Early Results of Modified Aortic-Valve Sparing Partial Root Replacement in Acute Type A Aortic Dissection with an Intimal Tear in the Aortic Sinuses Sung Kwang Lee, M.D., Ho-Ki Min, M.D., Woon Heo, M.D., Do Kyun Kang, M.D., Hee Jae Jun, M.D., and Youn-Ho Hwang, M.D. Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea ABSTRACT We describe a modified aortic valve-sparing partial root replacement (AVSPRR) technique for acute type A aortic dissection with an intimal tear (IT) in the aortic sinus. This procedure consists of selective replacement of the sinus containing an IT with a rectangular patch. If an IT exists in any coronary sinus, the coronary button was reimplanted to the neo-sinus and an external wrapping of the noncoronary sinus was added. Modified AVSPRR may be considered a feasible short-term outcome, and may be considered as an option in selected patients. doi: 10.1111/jocs.12524 (J Card Surg 2015;30:448–451)
In aortic dissection involving the aortic sinus, a composite graft replacement has become a standard technique. Valve-sparing root replacement (valve reimplantation and root remodeling) has been successfully applied to treat root pathologies. Some authors have applied it in aortic dissection and reported favorable results.1–6 However, this technique still remains controversial in the emergent situation because of prolonged duration and technical demands.7 We introduce our modified aortic valve-sparing partial root replacement (AVSPRR) technique applied when an intimal tear (IT) exists in the sinus of Valsalva and report early results. PATIENTS AND METHODS Between March 2010 and October 2014, we performed 50 surgeries for acute type A aortic dissection. Among them, five patients underwent a modified AVSPRR. All patients provided informed consent and Institutional Review Board permission was obtained. We considered the following as indications for our technique: (1) existence of an IT in the aortic sinus; (2) no valvular pathologies; (3) the maximal size of the root not exceeding 50 mm; and (4) no Address for correspondence: Ho-Ki Min, M.D., Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, Inje University College of Medicine, 875 (Jwadong) Haeundae-ro, Haeundaegu, Busan, 612-030, Korea. e-mail: [email protected]
connective tissue diseases. All patients underwent emergent surgery. Patients’ characteristics are described in Table 1. Surgical technique Cardiopulmonary bypass was conducted with biarterial cannulations (the right axillary and femoral arteries) and bicaval venous cannulations and systemic cooling was started. Following cardioplegic arrest with retrograde cardioplegia, the aorta was transected just above the sinotubular junction, and the intraaortic pathology was examined. If an IT existed in any coronary sinus, this involved sinus was partially mobilized down to the annular level including the proximal portion of the coronary artery. The sinus containing an IT was resected leaving 0.5 cmsized suture margin, and the coronary artery was detached from this sinus in a button fashion (Fig. 1B). Then gelatin-resorcinol-formaldehyde glue was applied fixation of the dissected layers of the other sinuses. Five subannular inside-out sutures of pledget-reinforced 4-0 polypropylene were placed in a horizontal mattress fashion just below the annulus; three were in line with each commissure and two were below the midpoint of the involved coronary and noncoronary sinuses (NCS) (Fig. 1B). A 5 cm long graft (Vascutek, Ltd., Inchinnan, UK) was cut from a cylindrical graft selected for ascending aorta replacement by sizing the sinotubular junction and the distal ascending aorta. It
J CARD SURG 2015;30:448–451
LEE, ET AL. VALVE-SPARING ROOT REPLACEMENT
449
TABLE 1 Patients’ Characteristics and Operative Data Annular Diameter (mm)
Root Diameter (mm)
AR Grade
Age Tear F/U No. Sex (year) Site Pre-op ! pre-D/C ! 1 Yr Pre-op ! pre-D/C ! 1 Yr Pre-op ! pre-D/C ! 1 Yr Results (Months) 1 2 3 4 5
M M F F M
49 31 71 55 46
right right left left left
26.5 ! 25.7 ! 25.5 26.3 ! 24.7 ! 24.6 25.7 ! 23.6 ! 23.6 ! 26.5 ! 25.1 ! -
45.3 ! 37.3 ! 38.9 44.7 ! 34.3 ! 34.8 50 ! 47 ! 34.5 ! 48 ! 40 ! -
trivial ! trivial ! trivial mild ! mild ! mild trivial ! trivial ! trivial ! trivial ! trivial ! trivial ! -
Alive Alive Dead Alive Alive
14 12 — 6 5
Pre-op ¼ preoperative; pre-D/C ¼ predischarge; 1 Yr ¼ 1 year later; AR ¼ aortic valve regurgitation; tear site ¼ involved coronary sinus; right ¼ the right coronary sinus; left ¼ the left coronary sinus.
was cut longitudinally and transformed to a rectangular shape (Fig. 1C). Five subannular sutures were passed through the base of a rectangular graft, reinforced with counter-pledgets, and tied down the root. The involved coronary sinus and NCS were wrapped externally using a rectangular graft, which stabilized over two thirds of the circumference of the root except the intact coronary sinus (Fig. 1D). Three commissural resuspensions to an external wrapping graft were performed using pledgetbuttressed 5-0 polypropylene sutures for proper commissural alignment and elevation to ensure valvular competency. The extra graft over the sinotubular junction was resected. The sinus remnant and annulus were fixed within a graft using continuous 5-0 polypropylene sutures. After confirmation for coapta-
tion, the coronary button was anastomosed to the neosinus with 5-0 polypropylene suture after creation of a small hole (Fig. 1D). In patient 4, the proximal portion was reconstructed because an IT was extended along the left main coronary artery. If an IT existed in the NCS, NCS was resected and replaced using the same method (Fig. 2). However, just three subannular stitches could be applied without a coronary manipulation; two were in line with each commissure and one was below the midpoint of NCS. This is much simpler than a case in which the coronary sinus was involved. Unfortunately, NCS was not involved in our series. Finally, the ascending aorta was replaced under circulatory arrest with selective cerebral perfusion.
Figure 1. Schematic diagrams of the operation when an intimal tear exists in any coronary sinus (A–D). The sinus containing an intimal tear was resected and the coronary artery was detached in a button fashion. About 5 cm long cylindrical graft was prepared and transformed to a rectangular shape by cutting longitudinally (dotted line in C). A partial wrapping graft was seated to cover the torn coronary and noncoronary sinuses after multiple subannular sutures were placed. Three commissural resuspensions were performed and the coronary button was reimplanted to the neo-aortic sinus. (E) After root reconstruction, proximal anastomosis was started. LCA, left coronary artery; RCA, right coronary artery.
450
LEE, ET AL. VALVE-SPARING ROOT REPLACEMENT
J CARD SURG 2015;30:448–451
Figure 2. Schematic diagrams of the operation when an intimal tear exists in the noncoronary sinus (A-D).
During the proximal anastomosis, suturing together the dissected layers with a wrapping graft was important for unifying the dissected layers. The right and the left sinuses were replaced in two and three patients, respectively (Table 1). RESULTS Mean pump and cross-clamping times were 313.8 35.0 minutes (range 291–375) and 232.4 19.1 minutes (range 207–254), respectively. One in-hospital mortality occurred due to septic shock. However, her echocardiography revealed trivial aortic regurgitation. In all survivors, there were no major complications. In the first two patients, 1-year follow-up echocardiograms revealed no significant changes in annular size, the size of the root, and the grade of aortic regurgitation (Table 1). Follow-up tomographic scans revealed patent grafts in all patients who remained asymptomatic during the follow-up period. DISCUSSION In aortic roots involved with an aortic dissection, valve-sparing root replacement can maintain the function and geometry of the the root. However, this technique is associated with prolonged operative times, an increased risk of bleeding, the possibility of aortic insufficiency, and technical issues with the coronary anastomosis. Thus, even centers with extensive experience with valve-sparing surgery do not recommend this method in patients with an acute aortic dissection.8 For this reason, the feasibility and effectiveness of valve-sparing surgery still remains controversial in the emergent situation.3,5,6
Recently, alternative techniques for valve-sparing surgery have been introduced and evolved to reduce surgical risk under emergency conditions.2,4 Effective substitutes should have certain requisites: (1) a faster and simpler procedure compared with other root replacement, (2) safety, and (3) greater physiological relevance. Compared with other techniques, our technique is easier and quicker because of a selective replacement of the involved sinus. Even if a coronary sinus is involved, only one coronary button needs to be reimplanted. For NCS involvement, this is much simpler because of just one sinus replacement without a coronary reimplantation. Furthermore, only one sinus replacement leaving the two intact native sinuses can maximally preserve the geometry of the root. A rectangular graft has some advantages. It is simpler to design and more resistant to bleeding compared to the Urbanski’s teardrop-shaped patch in which a graft was trimmed matching the size of the respective valve cusps.1,8 When a weakened root exists, even a slightly misplaced stitch may lead to intractable hemorrhage arising from deep and long suture lines because of its fragility. By double fixations of a remnant of aortic wall and the valve to a rectangular graft (one through subannular sutures below the valve and another through an internally continuous suture above the valve), our technique minimizes externally exposed suture lines compared with the Urbanski’s technique or root remodeling1,8and is more resistant to bleeding. Lastly, it can prevent future root dilatation. Supracommissural replacement is frequently selected because of technical simplicity and less invasiveness, but it is at risk for future complications, including dilatation, progressive aortic regurgitation, or redissection at the root.9 It is
J CARD SURG 2015;30:448–451
LEE, ET AL. VALVE-SPARING ROOT REPLACEMENT
well known that most of dilatation of the aortic annuls occurs beneath the commissures of the noncoronary cusp. Whether an IT exists in NCS or not, our procedure can ensure good stability of the aortic annulus beneath NCS by an external wrapping or replacement of NCS, which may be resistant to future dilatation. In conclusion, our technique may be feasible for acute type A aortic dissection with an IT in the aortic sinus. Thus, this might be an alternative valve-sparing technique in selected patients because of its simplicity and expected durability. REFERENCES 1. Urbanski PP: Valve-sparing aortic root repair with patch technique. Ann Thorac Surg 2005; 80(3): 839–43. 2. Chen L.W., Wu X.J., Li Q.Z., et al: A modified valve-sparing aortic root replacement technique for acute type A aortic dissection: The patch neointima technique. Eur J Cardiothorac Surg 2012; 42(4): 731–733.
451
3. Demers P, Miller DC.: Simple modification of ‘‘T. David-V‘‘ valve-sparing aortic root replacement to create graft pseudosinuses. Ann Thorac Surg 2004; 78(4): 1479–81. 4. Komiya T, Tamura N, Sakaguchi G, et al: Modified partial aortic root remodeling in acute type A aortic dissection. Interact Cardiovasc Thorac Surg 2009; 8(3): 306–9. 5. Hopkins RA.: Aortic valve leaflet sparing and salvage surgery: Evolution of techniques for aortic root reconstruction. Eur J Cardiothorac Surg 2003; 24(6): 886–97. 6. Shimizu H, Yozu R.: Valve-sparing aortic root replacement. Ann Thorac Cardiovasc Surg 2011;17: (4): 330–6. 7. Malvindi PG, van Putte BP, Sonker U, et al: Reoperation after acute type a aortic dissection repair: A series of 104 patients. Ann Thorac Surg 2013; 95(3): 922–7. 8. Urbanski PP, Hijazi H, Dinstak W, et al: Valve-sparing aortic root repair in acute type A dissection: How many sinuses have to be repaired for curative surgery? Eur J Cardiothorac Surg 2013; 44(3):439–43; discussion : 43-4. 9. Kallenbach K, Oelze T, Salcher R, et al: Evolving strategies for treatment of acute aortic dissection type A. Circulation 2004; 110(11 Suppl 1): II243–9.
448
SURGICAL TECHNIQUE ___________________________________________________________
Early Results of Modified Aortic-Valve Sparing Partial Root Replacement in Acute Type A Aortic Dissection with an Intimal Tear in the Aortic Sinuses Sung Kwang Lee, M.D., Ho-Ki Min, M.D., Woon Heo, M.D., Do Kyun Kang, M.D., Hee Jae Jun, M.D., and Youn-Ho Hwang, M.D. Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea ABSTRACT We describe a modified aortic valve-sparing partial root replacement (AVSPRR) technique for acute type A aortic dissection with an intimal tear (IT) in the aortic sinus. This procedure consists of selective replacement of the sinus containing an IT with a rectangular patch. If an IT exists in any coronary sinus, the coronary button was reimplanted to the neo-sinus and an external wrapping of the noncoronary sinus was added. Modified AVSPRR may be considered a feasible short-term outcome, and may be considered as an option in selected patients. doi: 10.1111/jocs.12524 (J Card Surg 2015;30:448–451)
In aortic dissection involving the aortic sinus, a composite graft replacement has become a standard technique. Valve-sparing root replacement (valve reimplantation and root remodeling) has been successfully applied to treat root pathologies. Some authors have applied it in aortic dissection and reported favorable results.1–6 However, this technique still remains controversial in the emergent situation because of prolonged duration and technical demands.7 We introduce our modified aortic valve-sparing partial root replacement (AVSPRR) technique applied when an intimal tear (IT) exists in the sinus of Valsalva and report early results. PATIENTS AND METHODS Between March 2010 and October 2014, we performed 50 surgeries for acute type A aortic dissection. Among them, five patients underwent a modified AVSPRR. All patients provided informed consent and Institutional Review Board permission was obtained. We considered the following as indications for our technique: (1) existence of an IT in the aortic sinus; (2) no valvular pathologies; (3) the maximal size of the root not exceeding 50 mm; and (4) no Address for correspondence: Ho-Ki Min, M.D., Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, Inje University College of Medicine, 875 (Jwadong) Haeundae-ro, Haeundaegu, Busan, 612-030, Korea. e-mail: [email protected]
connective tissue diseases. All patients underwent emergent surgery. Patients’ characteristics are described in Table 1. Surgical technique Cardiopulmonary bypass was conducted with biarterial cannulations (the right axillary and femoral arteries) and bicaval venous cannulations and systemic cooling was started. Following cardioplegic arrest with retrograde cardioplegia, the aorta was transected just above the sinotubular junction, and the intraaortic pathology was examined. If an IT existed in any coronary sinus, this involved sinus was partially mobilized down to the annular level including the proximal portion of the coronary artery. The sinus containing an IT was resected leaving 0.5 cmsized suture margin, and the coronary artery was detached from this sinus in a button fashion (Fig. 1B). Then gelatin-resorcinol-formaldehyde glue was applied fixation of the dissected layers of the other sinuses. Five subannular inside-out sutures of pledget-reinforced 4-0 polypropylene were placed in a horizontal mattress fashion just below the annulus; three were in line with each commissure and two were below the midpoint of the involved coronary and noncoronary sinuses (NCS) (Fig. 1B). A 5 cm long graft (Vascutek, Ltd., Inchinnan, UK) was cut from a cylindrical graft selected for ascending aorta replacement by sizing the sinotubular junction and the distal ascending aorta. It
J CARD SURG 2015;30:448–451
LEE, ET AL. VALVE-SPARING ROOT REPLACEMENT
449
TABLE 1 Patients’ Characteristics and Operative Data Annular Diameter (mm)
Root Diameter (mm)
AR Grade
Age Tear F/U No. Sex (year) Site Pre-op ! pre-D/C ! 1 Yr Pre-op ! pre-D/C ! 1 Yr Pre-op ! pre-D/C ! 1 Yr Results (Months) 1 2 3 4 5
M M F F M
49 31 71 55 46
right right left left left
26.5 ! 25.7 ! 25.5 26.3 ! 24.7 ! 24.6 25.7 ! 23.6 ! 23.6 ! 26.5 ! 25.1 ! -
45.3 ! 37.3 ! 38.9 44.7 ! 34.3 ! 34.8 50 ! 47 ! 34.5 ! 48 ! 40 ! -
trivial ! trivial ! trivial mild ! mild ! mild trivial ! trivial ! trivial ! trivial ! trivial ! trivial ! -
Alive Alive Dead Alive Alive
14 12 — 6 5
Pre-op ¼ preoperative; pre-D/C ¼ predischarge; 1 Yr ¼ 1 year later; AR ¼ aortic valve regurgitation; tear site ¼ involved coronary sinus; right ¼ the right coronary sinus; left ¼ the left coronary sinus.
was cut longitudinally and transformed to a rectangular shape (Fig. 1C). Five subannular sutures were passed through the base of a rectangular graft, reinforced with counter-pledgets, and tied down the root. The involved coronary sinus and NCS were wrapped externally using a rectangular graft, which stabilized over two thirds of the circumference of the root except the intact coronary sinus (Fig. 1D). Three commissural resuspensions to an external wrapping graft were performed using pledgetbuttressed 5-0 polypropylene sutures for proper commissural alignment and elevation to ensure valvular competency. The extra graft over the sinotubular junction was resected. The sinus remnant and annulus were fixed within a graft using continuous 5-0 polypropylene sutures. After confirmation for coapta-
tion, the coronary button was anastomosed to the neosinus with 5-0 polypropylene suture after creation of a small hole (Fig. 1D). In patient 4, the proximal portion was reconstructed because an IT was extended along the left main coronary artery. If an IT existed in the NCS, NCS was resected and replaced using the same method (Fig. 2). However, just three subannular stitches could be applied without a coronary manipulation; two were in line with each commissure and one was below the midpoint of NCS. This is much simpler than a case in which the coronary sinus was involved. Unfortunately, NCS was not involved in our series. Finally, the ascending aorta was replaced under circulatory arrest with selective cerebral perfusion.
Figure 1. Schematic diagrams of the operation when an intimal tear exists in any coronary sinus (A–D). The sinus containing an intimal tear was resected and the coronary artery was detached in a button fashion. About 5 cm long cylindrical graft was prepared and transformed to a rectangular shape by cutting longitudinally (dotted line in C). A partial wrapping graft was seated to cover the torn coronary and noncoronary sinuses after multiple subannular sutures were placed. Three commissural resuspensions were performed and the coronary button was reimplanted to the neo-aortic sinus. (E) After root reconstruction, proximal anastomosis was started. LCA, left coronary artery; RCA, right coronary artery.
450
LEE, ET AL. VALVE-SPARING ROOT REPLACEMENT
J CARD SURG 2015;30:448–451
Figure 2. Schematic diagrams of the operation when an intimal tear exists in the noncoronary sinus (A-D).
During the proximal anastomosis, suturing together the dissected layers with a wrapping graft was important for unifying the dissected layers. The right and the left sinuses were replaced in two and three patients, respectively (Table 1). RESULTS Mean pump and cross-clamping times were 313.8 35.0 minutes (range 291–375) and 232.4 19.1 minutes (range 207–254), respectively. One in-hospital mortality occurred due to septic shock. However, her echocardiography revealed trivial aortic regurgitation. In all survivors, there were no major complications. In the first two patients, 1-year follow-up echocardiograms revealed no significant changes in annular size, the size of the root, and the grade of aortic regurgitation (Table 1). Follow-up tomographic scans revealed patent grafts in all patients who remained asymptomatic during the follow-up period. DISCUSSION In aortic roots involved with an aortic dissection, valve-sparing root replacement can maintain the function and geometry of the the root. However, this technique is associated with prolonged operative times, an increased risk of bleeding, the possibility of aortic insufficiency, and technical issues with the coronary anastomosis. Thus, even centers with extensive experience with valve-sparing surgery do not recommend this method in patients with an acute aortic dissection.8 For this reason, the feasibility and effectiveness of valve-sparing surgery still remains controversial in the emergent situation.3,5,6
Recently, alternative techniques for valve-sparing surgery have been introduced and evolved to reduce surgical risk under emergency conditions.2,4 Effective substitutes should have certain requisites: (1) a faster and simpler procedure compared with other root replacement, (2) safety, and (3) greater physiological relevance. Compared with other techniques, our technique is easier and quicker because of a selective replacement of the involved sinus. Even if a coronary sinus is involved, only one coronary button needs to be reimplanted. For NCS involvement, this is much simpler because of just one sinus replacement without a coronary reimplantation. Furthermore, only one sinus replacement leaving the two intact native sinuses can maximally preserve the geometry of the root. A rectangular graft has some advantages. It is simpler to design and more resistant to bleeding compared to the Urbanski’s teardrop-shaped patch in which a graft was trimmed matching the size of the respective valve cusps.1,8 When a weakened root exists, even a slightly misplaced stitch may lead to intractable hemorrhage arising from deep and long suture lines because of its fragility. By double fixations of a remnant of aortic wall and the valve to a rectangular graft (one through subannular sutures below the valve and another through an internally continuous suture above the valve), our technique minimizes externally exposed suture lines compared with the Urbanski’s technique or root remodeling1,8and is more resistant to bleeding. Lastly, it can prevent future root dilatation. Supracommissural replacement is frequently selected because of technical simplicity and less invasiveness, but it is at risk for future complications, including dilatation, progressive aortic regurgitation, or redissection at the root.9 It is
J CARD SURG 2015;30:448–451
LEE, ET AL. VALVE-SPARING ROOT REPLACEMENT
well known that most of dilatation of the aortic annuls occurs beneath the commissures of the noncoronary cusp. Whether an IT exists in NCS or not, our procedure can ensure good stability of the aortic annulus beneath NCS by an external wrapping or replacement of NCS, which may be resistant to future dilatation. In conclusion, our technique may be feasible for acute type A aortic dissection with an IT in the aortic sinus. Thus, this might be an alternative valve-sparing technique in selected patients because of its simplicity and expected durability. REFERENCES 1. Urbanski PP: Valve-sparing aortic root repair with patch technique. Ann Thorac Surg 2005; 80(3): 839–43. 2. Chen L.W., Wu X.J., Li Q.Z., et al: A modified valve-sparing aortic root replacement technique for acute type A aortic dissection: The patch neointima technique. Eur J Cardiothorac Surg 2012; 42(4): 731–733.
451
3. Demers P, Miller DC.: Simple modification of ‘‘T. David-V‘‘ valve-sparing aortic root replacement to create graft pseudosinuses. Ann Thorac Surg 2004; 78(4): 1479–81. 4. Komiya T, Tamura N, Sakaguchi G, et al: Modified partial aortic root remodeling in acute type A aortic dissection. Interact Cardiovasc Thorac Surg 2009; 8(3): 306–9. 5. Hopkins RA.: Aortic valve leaflet sparing and salvage surgery: Evolution of techniques for aortic root reconstruction. Eur J Cardiothorac Surg 2003; 24(6): 886–97. 6. Shimizu H, Yozu R.: Valve-sparing aortic root replacement. Ann Thorac Cardiovasc Surg 2011;17: (4): 330–6. 7. Malvindi PG, van Putte BP, Sonker U, et al: Reoperation after acute type a aortic dissection repair: A series of 104 patients. Ann Thorac Surg 2013; 95(3): 922–7. 8. Urbanski PP, Hijazi H, Dinstak W, et al: Valve-sparing aortic root repair in acute type A dissection: How many sinuses have to be repaired for curative surgery? Eur J Cardiothorac Surg 2013; 44(3):439–43; discussion : 43-4. 9. Kallenbach K, Oelze T, Salcher R, et al: Evolving strategies for treatment of acute aortic dissection type A. Circulation 2004; 110(11 Suppl 1): II243–9.
