Abstract
Aortic valve replacement is the standard surgical procedure for severe aortic regurgitation. Due to advances over the past decade, there have been substantial improvements in aortic root graft design, in aortic valve repair techniques, and in the understanding of valvular function in the remodeled aortic root. Herein, we describe the case of a dyspneic patient with an asymmetric bicuspid aortic valve who underwent valve-sparing aortic root replacement and tricuspidization. The patient subsequently resumed strenuous physical activity and was asymptomatic 2 years after the operation.
Key words: Aortic diseases/pathology/surgery/ultrasonography, aortic valve/abnormalities, aortic valve insufficiency/complications/surgery/ultrasonography, cardiac surgical procedures/methods, suture techniques, treatment outcome
The conventional surgery for severe aortic regurgitation has been aortic valve replacement. This procedure, however, may soon become obsolete due to advances in aortic valve repair. Over the past decade, there have been substantial improvements in aortic root graft design, in aortic valve repair technique, and in the understanding of valvular function in the remodeled aortic root.1–7 Herein, we describe the case of a patient with complex aortic root disease who underwent surgical repair.
Clinical Summary
In September 2007, a 44-year-old obese man (body mass index, 32) presented with severe shortness of breath upon minimal exercise. The dyspnea had worsened over several months. Echocardiography showed severe aortic insufficiency and root dilation. In addition, magnetic resonance imaging showed severe aortic insufficiency (Figs. 1A and 1B) with a regurgitant fraction of 0.52, left ventricular (LV) dilation with a LV end-diastolic volume index of 152 mL/m2, and a LV ejection fraction of 0.45 with global impairment of LV function but no regional wall-motion abnormalities. Aortic root dimensions were 26 mm at the aortic valve annulus, 70 mm at the sinuses of Valsalva, 37 mm at the sinotubular (ST) junction, 33 mm at the mid-ascending aorta, and 30 mm at the level of the brachiocephalic artery. The functionally bicuspid aortic valve exhibited partial commissural fusion between the left coronary cusp (LCC) and the right coronary cusp (RCC) with asymmetric enlargement of the RCC component (Figs. 2A, 2B, and 2C). The aneurysm caused mild right ventricular outflow tract obstruction (Figs. 2A and 2B). Coronary angiography showed substantial stenoses in the left anterior descending coronary artery and the dominant right coronary artery. The patient, a farmer who operated heavy machinery, was reluctant to take warfarin for long-term anticoagulation, when he was offered the option of prosthetic valve replacement.
Fig. 1 Magnetic resonance imaging shows A) and B) severe aortic insufficiency and aortic root dilation preoperatively and C) restoration of normal geometry of the aortic root after the valve-sparing procedure.
Fig. 2 Magnetic resonance imaging of the aortic valve (short-axis view) shows A) the asymmetric opening of the aortic valve with fused right and left coronary cusps, and B) the central jet showing aortic insufficiency and the substantially larger right coronary cusp. C) Schematic drawing shows a surgical view of the aortic valve with the dilated right coronary cusp and commissural fusion between the left and right coronary cusps. D) and E) Magnetic resonance imaging (short-axis view) shows the restoration of a normally sized aortic root with symmetric closure of the aortic valve. F) Schematic drawing shows the aortic valve after plication and resuspension of the right coronary cusp.
Surgical Technique
Valve-sparing aortic root replacement was performed with use of a 28-mm Gelweave Valsalva™ graft (Vascutek®, part of TERUMO CardioVascular Systems Corp.; Ann Arbor, Mich). The fused raphe between the LCC and RCC was divided. Plication and resuspension of the RCC was performed with use of a 5-0 GORE-TEX® polytetrafluoroethylene suture (W.L. Gore & Associates, Inc.; Flagstaff, Ariz), which was first run in a mattress--stitch fashion through the free edge of the cusp to resuspend it at the proper coaptation level and then in an over-and-over fashion to ensure even plication of the cusp (Fig. 2F). Symmetric tricuspidization of the valve was thus achieved (Figs. 2D and 2E). The coronary ostia were reimplanted into the graft in standard fashion. The coronary arteries were bypassed with saphenous vein grafts: both proximal anastomoses were placed above the graft onto the normal ascending aorta. The coronary artery bypass operation did not add substantially to the complexity of the procedure.
The patient's postoperative course was uneventful. Magnetic resonance imaging, performed before the patient's discharge from the hospital, showed a competent and symmetric aortic valve (Figs. 1C, 2D, and 2E). The LV end-diastolic volume index decreased to 110 mL/m2. The patient was able to return to strenuous physical activity and was asymptomatic 2 years after surgery.
Discussion
Good long-term results of valve-sparing aortic root replacement have expanded the application of this procedure to more complex valvular disorders.1–3 Valve-sparing aortic root replacement provides durable results in tricuspid and bicuspid valve anatomies, provided that aggressive correction of the cusp prolapse is performed.2,3 In our patient, partial fusion of the LCC and the RCC in combination with marked enlargement of the RCC made simple valve-sparing root replacement difficult. Reduction of the root diameter would have inevitably resulted in a prolapse of the larger cusp. Uneven contribution of the fused LCC and RCC components to a common aortic valve cusp precluded restoration of the valvular anatomy and function as a bicuspid aortic valve. Conversely, tricuspidization enabled the precise reduction and resuspension of the enlarged RCC and the restoration of aortic valve symmetry in the remodeled root. Tricuspidization of a bicuspid valve has been performed in adults and children with good results.4,5
Thorough preoperative planning is essential before a patient undergoes complex aortic root surgery and concurrent coronary artery bypass. Magnetic resonance imaging was useful in the preoperative planning and in the postoperative follow-up of our patient. Tricuspidization with cusp remodeling in combination with valve-sparing root replacement can be a valuable alternative to aortic root replacement in patients who have complex aortic root anatomy.
Footnotes
Address for reprints: Igor E. Konstantinov, MD, PhD, Cardiac Surgery Unit, Royal Children's Hospital, Flemington Rd., Parkville, Victoria 3052, Australia
E-mail: konstantinov.igor@alumni.mayo.edu
References
- 1.David TE, Feindel CM, Webb GD, Colman JM, Armstrong S, Maganti M. Long-term results of aortic valve-sparing operations for aortic root aneurysm. J Thorac Cardiovasc Surg 2006;132(2):347–54. [DOI] [PubMed]
- 2.Aicher D, Langer F, Lausberg H, Bierbach B, Schafers HJ. Aortic root remodeling: ten-year experience with 274 patients. J Thorac Cardiovasc Surg 2007;134(4):909–15. [DOI] [PubMed]
- 3.Schafers HJ, Aicher D, Langer F, Lausberg HF. Preservation of the bicuspid aortic valve. Ann Thorac Surg 2007;83(2):S740-5. [DOI] [PubMed]
- 4.Kawazoe K, Izumoto H, Tsuboi J, Koizumi J. Tricuspidization of incompetent bicuspid aortic valve. J Thorac Cardiovasc Surg 2003;126(3):908–10. [DOI] [PubMed]
- 5.McMullan DM, Oppido G, Davies B, Kawahira Y, Cochrane AD, d'Udekem d'Acoz Y, et al. Surgical strategy for the bicuspid aortic valve: tricuspidization with cusp extension versus pulmonary autograft. J Thorac Cardiovasc Surg 2007;134(1): 90–8. [DOI] [PubMed]
- 6.Zehr KJ, Thubrikar MJ, Gong GG, Headrick JR, Robicsek F. Clinical introduction of a novel prosthesis for valve-preserving aortic root reconstruction for annuloaortic ectasia. J Thorac Cardiovasc Surg 2000;120(4):692–8. [DOI] [PubMed]
- 7.Konstantinov IE, Zehr KJ. Aortic insufficiency in a patient with Marfan syndrome after aortic root reconstruction with a tailored-sinus graft. Tex Heart Inst J 2003;30(3):243–5. [PMC free article] [PubMed]