Case Study
Prosthesis-sparing aortic root replacement following aortic valve replacement
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(6) 734–736 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313482316 aan.sagepub.com
Tamaki Takano, Yuko Wada, Tatsuichiro Seto, Takamitsu Terasaki, Daisuke Fukui and Jun Amano
Abstract Reoperation on the aortic root is considered to be challenging because of high hospital mortality. Prosthesis-sparing aortic root replacement, in which the aortic prosthesis is preserved during reoperation, and could avoid passing sutures through the weakened aortic annuls after the initial prosthesis has been removed. We report 3 cases of prosthesissparing aortic root replacement. Prior procedures were aortic valve replacement and the Bentall operation 14 to 35 years previously. Postoperative courses were uneventful, with no signs of pseudoaneurysm or valve malfunction observed during follow-up periods of 93 to 360 days.
Keywords Aorta, Aortic aneurysm, thoracic, Blood vessel prosthesis implantation, Heart valve prosthesis, Reoperation
Introduction Reoperation on the aortic root and ascending aorta is sometimes indicated for aneurysm, pseudoaneurysm, or aortic root dissection after aortic valve replacement, but is considered to be a challenging procedure with as high as 12% hospital mortality in a current report.1 During reoperation, the prosthetic aortic valve usually needs to be completely replaced with a composite valve graft.1,2 There are only a few reports describing prosthesis-sparing aortic root replacement in which the aortic prosthesis is preserved during reoperation on the aortic root.3,4 We report 3 cases of prosthesis-sparing aortic root replacement with early and midterm outcomes.
Case reports CASE 1
A 66-year-old man, who had undergone aortic valve replacement with a 25-mm St. Jude mechanical valve for aortic regurgitation after aortic dissection 22 years earlier, complained of leg edema and anorexia. Computed tomography showed aortic root and arch dilatation with a maximal diameter of 60 mm, and echocardiography revealed severe tricuspid regurgitation.
Intraoperative transesophageal echocardiography revealed no pannus or thrombus. We performed prosthesis-sparing aortic root replacement with total arch replacement and tricuspid annuloplasty. The ascending aorta was crossclamped and the aneurysm was opened after initiation of cardiopulmonary bypass. The prosthetic valve was carefully inspected for thrombi, pannus, or annular dehiscence, and leaflet motion was verified with a valve tester after cardiac arrest was achieved. A new vascular graft, 3 mm larger than the initial aortic prosthetic valve, was anastomosed to the prosthesis cuff after placing 20 mattress sutures through the aortic wall remnant and prosthesis cuff, from outside to inside, using 2/0 polypropylene sutures with spaghetti (Figures 1 and 2). Adhesions were severe and the coronary buttons were difficult to make, a small vascular graft of 8 mm in diameter was anastomosed to the left coronary orifice prior to graft-prosthesis cuff anastomosis (Figure 3), followed by right coronary reconstruction in the same manner as the left coronary artery.
Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan Corresponding author: Tamaki Takano, MD, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at UNIVERSITY OF ALBERTA LIBRARY on April 25, 2015
Takano et al.
735
Figure 1. Diagram showing the 2/0 polypropylene sutures with spaghetti passed through the prosthetic cuff from outside to inside.
Figure 3. A small vascular graft is anastomosed prior to graftprosthesis cuff anastomosis.
root was noted, and after 5 years, its size had gradually increased to 57 mm. No pannus or thrombus was observed on the aortic prosthesis by echocardiography, and valve function was normal. We performed prosthesis-sparing aortic root replacement with a continuous suture of 4/0 polypropylene for graft-prosthesis cuff anastomosis. The operative time was 7 h 13 min with crossclamping for 194 min, blood loss of 1129 mL, intubation for 1 day, and 1 night in the intensive care unit. The postoperative course was uncomplicated, and there has been no sign of valve malfunction or pseudoaneurysm in 285 days of observation. CASE 3 Figure 2. A vascular graft of the size of the spared prosthesis þ3 mm is selected. The sutures are tied, and the anastomosis is completed.
The operative time was 14 h 24 min, with aortic crossclamping for 268 min, and blood loss of 3778 mL. The patient was extubated on the operative day and moved to a general ward on postoperative day 1. No valve malfunction or pseudoaneurysm in the aortic root were detected in 360 days of follow-up. CASE 2
A 64-year-old woman received a Bentall operation with a 23-mm Bjork-Shiley mechanical valve and a vascular graft. Thirty years later, pseudoaneurysm of the aortic
A 68-year-old man underwent valve replacement with a 25-mm St. Jude mechanical valve 14 years earlier, for aortic regurgitation. His aortic root enlarged to 68 mm in diameter during follow-up. We performed prosthesis-sparing aortic root replacement after valve disfunction and pannus were excluded by echocardiography and direct inspection during surgery. The coronary ostia were mobilized, coronary buttons were made, and a new vascular graft was anastomosed to the prosthesis cuff with 19 mattress sutures. The coronary buttons were anastomosed to the graft in the standard fashion. The operative time was 8 h 20 min with crossclamping for 171 min, blood loss of 574 mL, intubation for 1 day, and 1 night in the intensive care unit. No complication was observed during hospital stay, and no signs of pseudoaneurysm or valve malfunction were observed during follow-up of 93 days.
Downloaded from aan.sagepub.com at UNIVERSITY OF ALBERTA LIBRARY on April 25, 2015
736
Asian Cardiovascular & Thoracic Annals 22(6) Conflict of interest statement
Discussion Prosthesis-sparing aortic root replacement preserves the non-damaged prosthesis and may avoid damage to the aortic annulus and annular apparatus when explanting an old prosthesis. No mechanical failures were found in the 25-year follow up of the Medtronic-Hall valve prosthesis, which is a widely used mechanical heart valve from 1970-80, and valve thrombosis associated with pannus formation was seen in only 1 of 816 patients.5 We did not find any thrombus or pannus on the primary aortic prosthesis, and could preserve the prosthesis in these 3 cases. Recent papers have reported that the hospital mortality of reoperation on the aortic root reached 12%, and prolonged intensive care unit stay, postoperative renal failure, and reexploration for bleeding were all more common in aortic root reoperations.1,2 In our cases, all patients were extubated on the operative day and stayed in the intensive care unit for one night. We expect prosthesis-sparing aortic root replacement to reduce hospital mortality, intensive care unit stay, and morbidity, and are planning long-term follow-up studies in larger cohorts to evaluate the function of spared prostheses.
None declared
References 1. Silva J, Maroto LC, Carnero M, et al. Ascending aorta and aortic root reoperations: are outcomes worse than first time surgery? Ann Thorac Surg 2010; 90: 555–560. 2. Davierwala PM, Borger MA, David TE, Rao V, Maganti M and Yau TM. Reoperation is not an independent predictor of mortality during aortic valve surgery. J Thorac Cardiovasc Surg 2006; 131: 329–335. 3. Pacini D, Villa E, Martin-Suarez S and Bartolomeo RD. Aortic root substitution after aortic valve replacement: a prosthesis-sparing operation. Eur J Cardiothorac Surg 2005; 27: 717–719. 4. Luciani N, Anselmi A, de Geest R, Glieca F and Possati G. Facilitated aortic root substitution after aortic valve replacement: technique and results of the prosthesis-sparing operation. J Thorac Cardiovasc Surg 2010; 139: 785–787. 5. Svennevig JL, Abdelnoor M and Nitter-Hauge S. Twenty-five-year experience with the Medtronic-Hall valve prosthesis in the aortic position: a follow-up cohort study of 816 consecutive patients. Circulation 2007; 116: 1795–1800.
Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Downloaded from aan.sagepub.com at UNIVERSITY OF ALBERTA LIBRARY on April 25, 2015
Prosthesis-sparing aortic root replacement following aortic valve replacement
Asian Cardiovascular & Thoracic Annals 2014, Vol. 22(6) 734–736 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313482316 aan.sagepub.com
Tamaki Takano, Yuko Wada, Tatsuichiro Seto, Takamitsu Terasaki, Daisuke Fukui and Jun Amano
Abstract Reoperation on the aortic root is considered to be challenging because of high hospital mortality. Prosthesis-sparing aortic root replacement, in which the aortic prosthesis is preserved during reoperation, and could avoid passing sutures through the weakened aortic annuls after the initial prosthesis has been removed. We report 3 cases of prosthesissparing aortic root replacement. Prior procedures were aortic valve replacement and the Bentall operation 14 to 35 years previously. Postoperative courses were uneventful, with no signs of pseudoaneurysm or valve malfunction observed during follow-up periods of 93 to 360 days.
Keywords Aorta, Aortic aneurysm, thoracic, Blood vessel prosthesis implantation, Heart valve prosthesis, Reoperation
Introduction Reoperation on the aortic root and ascending aorta is sometimes indicated for aneurysm, pseudoaneurysm, or aortic root dissection after aortic valve replacement, but is considered to be a challenging procedure with as high as 12% hospital mortality in a current report.1 During reoperation, the prosthetic aortic valve usually needs to be completely replaced with a composite valve graft.1,2 There are only a few reports describing prosthesis-sparing aortic root replacement in which the aortic prosthesis is preserved during reoperation on the aortic root.3,4 We report 3 cases of prosthesis-sparing aortic root replacement with early and midterm outcomes.
Case reports CASE 1
A 66-year-old man, who had undergone aortic valve replacement with a 25-mm St. Jude mechanical valve for aortic regurgitation after aortic dissection 22 years earlier, complained of leg edema and anorexia. Computed tomography showed aortic root and arch dilatation with a maximal diameter of 60 mm, and echocardiography revealed severe tricuspid regurgitation.
Intraoperative transesophageal echocardiography revealed no pannus or thrombus. We performed prosthesis-sparing aortic root replacement with total arch replacement and tricuspid annuloplasty. The ascending aorta was crossclamped and the aneurysm was opened after initiation of cardiopulmonary bypass. The prosthetic valve was carefully inspected for thrombi, pannus, or annular dehiscence, and leaflet motion was verified with a valve tester after cardiac arrest was achieved. A new vascular graft, 3 mm larger than the initial aortic prosthetic valve, was anastomosed to the prosthesis cuff after placing 20 mattress sutures through the aortic wall remnant and prosthesis cuff, from outside to inside, using 2/0 polypropylene sutures with spaghetti (Figures 1 and 2). Adhesions were severe and the coronary buttons were difficult to make, a small vascular graft of 8 mm in diameter was anastomosed to the left coronary orifice prior to graft-prosthesis cuff anastomosis (Figure 3), followed by right coronary reconstruction in the same manner as the left coronary artery.
Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan Corresponding author: Tamaki Takano, MD, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at UNIVERSITY OF ALBERTA LIBRARY on April 25, 2015
Takano et al.
735
Figure 1. Diagram showing the 2/0 polypropylene sutures with spaghetti passed through the prosthetic cuff from outside to inside.
Figure 3. A small vascular graft is anastomosed prior to graftprosthesis cuff anastomosis.
root was noted, and after 5 years, its size had gradually increased to 57 mm. No pannus or thrombus was observed on the aortic prosthesis by echocardiography, and valve function was normal. We performed prosthesis-sparing aortic root replacement with a continuous suture of 4/0 polypropylene for graft-prosthesis cuff anastomosis. The operative time was 7 h 13 min with crossclamping for 194 min, blood loss of 1129 mL, intubation for 1 day, and 1 night in the intensive care unit. The postoperative course was uncomplicated, and there has been no sign of valve malfunction or pseudoaneurysm in 285 days of observation. CASE 3 Figure 2. A vascular graft of the size of the spared prosthesis þ3 mm is selected. The sutures are tied, and the anastomosis is completed.
The operative time was 14 h 24 min, with aortic crossclamping for 268 min, and blood loss of 3778 mL. The patient was extubated on the operative day and moved to a general ward on postoperative day 1. No valve malfunction or pseudoaneurysm in the aortic root were detected in 360 days of follow-up. CASE 2
A 64-year-old woman received a Bentall operation with a 23-mm Bjork-Shiley mechanical valve and a vascular graft. Thirty years later, pseudoaneurysm of the aortic
A 68-year-old man underwent valve replacement with a 25-mm St. Jude mechanical valve 14 years earlier, for aortic regurgitation. His aortic root enlarged to 68 mm in diameter during follow-up. We performed prosthesis-sparing aortic root replacement after valve disfunction and pannus were excluded by echocardiography and direct inspection during surgery. The coronary ostia were mobilized, coronary buttons were made, and a new vascular graft was anastomosed to the prosthesis cuff with 19 mattress sutures. The coronary buttons were anastomosed to the graft in the standard fashion. The operative time was 8 h 20 min with crossclamping for 171 min, blood loss of 574 mL, intubation for 1 day, and 1 night in the intensive care unit. No complication was observed during hospital stay, and no signs of pseudoaneurysm or valve malfunction were observed during follow-up of 93 days.
Downloaded from aan.sagepub.com at UNIVERSITY OF ALBERTA LIBRARY on April 25, 2015
736
Asian Cardiovascular & Thoracic Annals 22(6) Conflict of interest statement
Discussion Prosthesis-sparing aortic root replacement preserves the non-damaged prosthesis and may avoid damage to the aortic annulus and annular apparatus when explanting an old prosthesis. No mechanical failures were found in the 25-year follow up of the Medtronic-Hall valve prosthesis, which is a widely used mechanical heart valve from 1970-80, and valve thrombosis associated with pannus formation was seen in only 1 of 816 patients.5 We did not find any thrombus or pannus on the primary aortic prosthesis, and could preserve the prosthesis in these 3 cases. Recent papers have reported that the hospital mortality of reoperation on the aortic root reached 12%, and prolonged intensive care unit stay, postoperative renal failure, and reexploration for bleeding were all more common in aortic root reoperations.1,2 In our cases, all patients were extubated on the operative day and stayed in the intensive care unit for one night. We expect prosthesis-sparing aortic root replacement to reduce hospital mortality, intensive care unit stay, and morbidity, and are planning long-term follow-up studies in larger cohorts to evaluate the function of spared prostheses.
None declared
References 1. Silva J, Maroto LC, Carnero M, et al. Ascending aorta and aortic root reoperations: are outcomes worse than first time surgery? Ann Thorac Surg 2010; 90: 555–560. 2. Davierwala PM, Borger MA, David TE, Rao V, Maganti M and Yau TM. Reoperation is not an independent predictor of mortality during aortic valve surgery. J Thorac Cardiovasc Surg 2006; 131: 329–335. 3. Pacini D, Villa E, Martin-Suarez S and Bartolomeo RD. Aortic root substitution after aortic valve replacement: a prosthesis-sparing operation. Eur J Cardiothorac Surg 2005; 27: 717–719. 4. Luciani N, Anselmi A, de Geest R, Glieca F and Possati G. Facilitated aortic root substitution after aortic valve replacement: technique and results of the prosthesis-sparing operation. J Thorac Cardiovasc Surg 2010; 139: 785–787. 5. Svennevig JL, Abdelnoor M and Nitter-Hauge S. Twenty-five-year experience with the Medtronic-Hall valve prosthesis in the aortic position: a follow-up cohort study of 816 consecutive patients. Circulation 2007; 116: 1795–1800.
Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Downloaded from aan.sagepub.com at UNIVERSITY OF ALBERTA LIBRARY on April 25, 2015
