Aortic Valve Resuspension

 

Introduction

Indications

Contraindications

Diagram

Technical Note

Diagram of Operation

Video

Pitfalls

Complications

Follow up

 


 

 

Introduction

 

Acute type A dissection

Acute type A dissection is complicated by aortic valve insufficiency in up to 75% of patients. Fortunately, preservation of the native valve is successful nearly 85% of the time. The mechanism of aortic insufficiency in most cases is the loss of commissural support of the valve leaflets. This is repaired using pledgeted 4-0 Prolene sutures to reposition each of the commissures at the sinotubular ridge. The dissected aortic root layers are then reunited using 3-0 Prolene suture and either one or two strips of Teflon felt. Bioglue is placed between the layers prior to suture repair of the sinotubular ridge to buttress the repair and reform the sinuses of Valsalva. Aortic valve preservation must always be performed using intraoperative transesophageal echocardiography to assess the valve postoperatively. No more than mild aortic insufficiency should be present. In addition to commissural resuspension, techniques exist to spare the aortic valve and replace the aortic root in acute type A dissection, but the experience is early and the number of patients few.

 

Chronic type A dissection

Whereas the aortic valve can be repaired in most cases of acute type A dissection by simple commissural resuspension, the rate of aortic valve replacement is much higher in patients with chronic dissection. Preservation of the aortic valve is complicated by morphologic changes in the valvular apparatus such as leaflet elongation and annuloaortic ectasia, which render the valve irreparable in as many as 50%. More severe grades of preoperative aortic regurgitation portend a lower probability of valve preservation. In cases where the aortic valve cannot be preserved with simple commissural reattachment, three options exist to treat aortic insufficiency: composite valve-graft replacement, aortic valve replacement with separate ascending aortic replacement, and finally valve-sparing aortic root repair.

 

Indications

Aortic regurgitation in the setting of aortic dissection.

 

Contraindications

Calcified valve

?Bicuspid valve

Marfans, this procedure leaves residual aortic tissue in place.

Connective tissue disorder

 

Diagram

 

Resuspension and preservation of the native aortic valve in a type A dissection. The dissected layers are approximated at each commissure with double pledgeted mattress sutures. Completed resuspension of the aortic valve commissures. Thin felt strips (810 mm wide) are placed inside and outside around the circumference of the aorta. The coronary ostia are not compromised. The aortic walls are sandwiched between the felt strips with horizontal mattress sutures. A vascular graft is sutured to the reconstructed proximal aorta.

 

Technical Note

Teflon resuspension of the commisures is key to this procedure working. Testing the valve with water after resuspension is also key to achieving a low rate of postoperative aortic regurgitation.

 

Diagram of Operation

Video

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Pitfalls

-

 

Complications

Residual aortic regurgitation

 

Follow up

Routine with yearly echocardiography.