Interact CardioVasc Thorac Surg 2009;9:680-682. doi:10.1510/icvts.2009.211367
© 2009 European Association of Cardio-Thoracic Surgery
Proposal for bail-out procedures - Valves |
Apico-aortic valved conduit as an alternative for aortic valve re-replacement in severe prosthesis–patient mismatch
Jamil Hajj Chahine*,
Issam El-Rassi and
Victor Jebara
Department of Cardio-thoracic Surgery, Hotel Dieu de France Hospital, Alfred Naccache Street, Beirut, Lebanon
Received 7 May 2009;
received in revised form 1 July 2009;
accepted 7 July 2009
*Corresponding author. Tel.: +961-1-615300; fax: +961-1-615295.
E-mail address: jamilhajjchahine{at}yahoo.fr (J. Hajj Chahine).
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Abstract
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Off-pump implantation of an apico-aortic bioprothesis-valved conduit in a 75-year-old female symptomatic patient with severe prosthesis–patient mismatch secondary to a previous aortic valve replacement, calcified ascending aorta, tight adhesion with the sternum, was successfully conducted to relieve the left ventricle from severe aortic stenosis.
Key Words: Aortic stenosis; Apico-aortic conduit; Prosthesis–patient mismatch
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1. Introduction
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To avoid prosthesis–patient mismatch in patients with relatively small aortic roots that are undergoing aortic valve replacement, multiple solutions are possible in the armamentarium of the cardio-thoracic surgeon. Aortic root enlargement is the standard procedure for patients with small aortic annulus. The use of stentless valves is also an alternative to minimize the prosthesis–patient mismatch [1]. All these techniques demonstrated relative success but at the expense of increased operative risk, especially in patients with severe comorbidities [2, 3].
We report the case of a patient suffering from severe mismatch secondary to a previous aortic valve replacement and a prohibitive predicted mortality for traditional surgical management. An apico-aortic valved conduit was successfully implanted and it was used as a bail-out procedure to aortic valve re-replacement.
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2. Case
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A 75-year-old female patient was admitted to our hospital with increasing symptoms of congestive heart failure. She had a history of aortic valve replacement five years previously with a 17-mm metallic aortic valve (SJM Regent, St Jude Medical Inc, St Paul, MN), and she was suffering from chronic renal insufficiency. On admission, echocardiogram demonstrated that the bileaflet valve was functioning normally but disclosed severe aortic stenosis with an aortic valve area of 0.6 cm2 and aortic valve gradient of 65 mmHg, and slightly reduced left ventricular ejection fraction. Multislice computed tomography (CT)-scan demonstrated a mildly calcified ascending aorta with tight adhesions between the sternum and the right ventricle. Cardiac catheterization was not performed due to an elevated level of serum creatinine. Preoperative risk scores predicted an operative mortality of >30%.
Due to the prohibitive predicted mortality for the traditional re-replacement with aortic root enlargement, we preferred to schedule our patient for an apico-aortic valved conduit implantation. Our strategy aimed to reduce the operative risk by avoiding the re-entry median sternotomy and the dissection of the aortic root, also by trying to implant the conduit with shorter period of cardiopulmonary bypass (CPB) and without aortic cross-clamping.
The patient was placed in the left lateral decubitus position. Anesthetic management consisted of placement of a double-lumen endotracheal tube for single-lung ventilation. The left pleural cavity was entered through the sixth intercostal's space incision centred along the mid-axillary line. After dividing the inferior pulmonary ligament, the lung was retracted; this allowed exposing the cardiac apex and the descending thoracic aorta. The patient was fully heparinized and the left femoral artery and vein were exposed in the event that CPB was necessary. The distal limb of the conduit was performed first. A 20-mm Dacron graft (Hemashield, Boston Scientific, Boston, MA) was sewn end-to-side to the descending aorta using a partial occluding clamp and a running 4-0 non-absorbable suture technique. The tube graft was then connected end-to-end to a 19-mm stented, porcine, valved conduit (Mosaic, Medtronic, Minneapolis, MN) with a continuous 4-0 non-absorbable suture.
The pericardium was then opened anterior to the phrenic nerve and the apex was exposed after careful dissection. An 18-gauge needle was passed through the apex and into the left ventricle. A guide wire and a series of dilators were then introduced before placing a 14-Fr occlusion balloon over the guide wire. A 20-mm ventricular coring device (Medtronic, Minneapolis, MN) was then threaded in-line over the catheter, thereby removing a core of ventricular muscle at the apex. The balloon occluded the circular opening of the ventricle while a 20-mm connector (Medtronic, Minneapolis, MN) was slid into place. The occlusion balloon was left in place while twelve interrupted pledgeted 2-0 non-absorbable sutures were sewn from the ventricular muscle around the opening to the external cuff of the rigid connector. The occlusion balloon was then removed and was replaced by an aortic clamp on the Dacron portion of the connector. The distal end of the apical connector was then sewn to the valved conduit with a running 4-0 non-absorbable suture. The graft was finally de-aired before removing the clamp. CPB was not required during the procedure.
The postoperative period was uneventful, CT-scan showed an intact and unobstructed conduit (Figs. 1 and 2). The patient was discharged on the tenth postoperative day with warfarin sodium for life.
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Fig. 1. Multi-detector computerized tomography showing the conduit between the apex and the descending aorta (axial view) and the metallic aortic valve.
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Fig. 2. Image reconstruction from a multi-detector computerized tomography showing the conduit between the apex and the descending aorta.
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At the last follow-up, the patient was asymptomatic and echocardiogram demonstrated reduced aortic valve gradient of 28 mmHg.
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3. Comment
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Techniques of aortic root enlargement have been previously described and are generally attributed to Nicks et al. [4] and to Manouguian and Seybold-Epting [5]. Several surgical series used these techniques [1, 2] and demonstrated relative success, but at the expense of increased operative risk. The use of apico-aortic valved conduit as a bail-out procedure had already been described in two different situations. The first case [6] concerned a patient with aortic stenosis and porcelain ascending aorta with a previous history of ‘aortic no touch’ off-pump coronary artery bypass grafting, and the second case [7] was successfully conducted in a patient suffering from the dilated phase of mid-ventricular obstructive hypertrophic cardiomyopathy with end-stage heart failure. We presented another case of aortic valve bypass surgery that was conducted successfully without CPB in a patient with prohibitive predicted mortality for the traditional re-replacement strategy for aortic root enlargement with severe comorbidities. Off-pump implantation of a second outflow tract, allows avoiding the detrimental effects of both CPB and cardiac ischemia. A small size valve used in the conduit is usually adequate as the effective postoperative orifice is the sum of the native and the prosthetic aortic valves [8]. Recently, an alternative to surgical aortic valve replacement in a subset of high-risk patients – the percutaneous aortic valve replacement – has emerged [9]. However, this option was excluded in our case because the deployment of percutaneous aortic valve replacement device is impossible in the setting of a metallic valve.
Apico-aortic valved conduit is a safe alternative to aortic valve re-replacement in patients with small annulus requiring complex and hazardous re-operation for severe and symptomatic prosthesis–patient mismatch.
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References
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- Kunihara T, Schmidt K, Glombitza P, Dzindzibadze V, Lausberg H, Schafers H-J. Root replacement using stentless valves in the small aortic root: a propensity score analysis. Ann Thorac Surg 2006;82:1379–1384.[Abstract/Free Full Text]
- Sommers KE, David TE. Aortic valve replacement with patch enlargement of the aortic annulus. Ann Thorac Surg 1997;63:1608–1612.[Abstract/Free Full Text]
- Pugliese P, Bernabei M, Santi C, Pasque A, Eufrate S. Posterior enlargement of the small annulus during aortic valve replacement versus implantation of a small prosthesis. Ann Thorac Surg 1983;38:31–36.
- Nicks R, Cartmill T, Bernstein L. Hypoplasia of the aortic root. Thorax 1970;25:339–346.[Abstract/Free Full Text]
- Manouguian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision to the anterior mitral leaflet. J Thorac Cardiovasc Surg 1979;78:402–412.[Abstract]
- Nishimura Y, Okamura Y, Hiramatsu T, Iwahashi M. Apicoaortic valved conduit is a good alternative for aortic stenosis with porcelain aorta after off-pump coronary artery bypass grafting. Interact CardioVasc Thorac Surg 2007;6:374–375.[Abstract/Free Full Text]
- Matsushita T, Kawase T, Tsuda E, Kawazoe K. Apicoaortic conduit for the dilated phase of hypertrophic obstructive cardiomyopathy as an alternative to heart transplantation. Interact CardioVasc Thorac Surg 2009;8:232–234.[Abstract/Free Full Text]
- Vassiliades T. Off-pump apicoaortic conduit insertion for high-risk patients with aortic stenosis. Eur J Cardiothorac Surg 2003;23:156–158.[Abstract/Free Full Text]
- Chiam PT, Ruiz CE. Percutaneous transcatheter aortic valve implantation: assessing results, judging outcomes, and planning trials: the interventionalist perspective. JACC Cardiovasc Interv 2008;1:341–350.[CrossRef][Medline]
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Abstract
1. Introduction