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Aortic Root Enlargement: Modified Manouguian Technique

Monday, April 25, 2016

By

Guillermo Stöger

The enlargement of the aortic annulus has demonstrated excellent results for avoiding patient-prosthesis mismatch (PPM). Aortic root enlargement (ARE) has been shown to be a safe and reproducible procedure. Several techniques are described in the literature, however, Nicks was a pioneer in describing the incision into the noncoronary sinus that allows aortic annulus enlargement (1). The benefit of this procedure is the implantation of a bigger valve prosthesis (by one or two sizes), thus avoiding PPM. The size of the aortic prosthesis should be proportional to the patient’s body surface. PPM is an important factor that affects mortality and morbidity.

Important Steps

  1. A median sternotomy was performed. 
  2. Cardiopulmonary bypass (CPB) was instituted with ascending aorta and right atrial cannulation through a two-stage cannula (Edwards Lifesciences, Irvine, California, USA).
  3. Left heart venting from the right superior pulmonary vein was added.
  4. The ascending aorta was clamped and antegrade and retrograde cardioplegia (CPL) with cold blood was performed.
  5. A transversal aortotomy was started and the aortic valve was exposed.
  6. The aortic valve was excised and the annulus was carefully debrided.
  7. When the decalcification of the annulus was finished, the annulus was measured with the corresponding sizers. The decision to enlarge the aortic annulus was made according to the patient's body surface.
  8. A dissection of the left atrium roof was made in order to make a clear incision.
  9. A modified Manouguian technique was performed without entering into the left atrium or incising the anterior leaflet of the mitral valve (2).
  10. The enlargement was achieved by extending the aortotomy into the fibrous tissue between the non-coronary cusp and the left coronary cusp and onto the subaortic curtain.
  11. The reconstruction of the defect was done with a teardrop-shaped glutaraldehyde-treated patch of bovine pericardium. This patch was sutured with a 5.0 polypropylene suture (Prolene®, Ethicon, New Jersey, USA), starting at the nadir of the annular enlargement incision and extending up to 1 or 2 cm above the plane of the annulus. At this level, the authors used an extra suture to fix the enlargement suture line with 5.0 polypropylene.
  12. The aortic annulus was resized.
  13. Pledgeted 2.0 polyester sutures (TiCron®, Covidien, Dublin, Ireland) were placed circumferentially around the aortic annulus (placing them from the outside into the patch zone).
  14. The sutures were placed in the prosthetic valve and then tied into place.
  15. The aortotomy was closed using the patch to enlarge the aortic root with a 5.0 polypropylene suture in a continuous fashion.
  16. After weaning from CPB, protamine was administered and the procedure was completed in a routine fashion.

The functions of the prosthesis and de-airing process were monitored with intraoperative transesophageal echocardiography. This technique allowed the implantation of a prosthetic valve one or two sizes larger than the original size of the aortic annulus.

References

  1. Nicks R, Cartmill T, Bernstein L. Hypoplasia of the aortic root. The problem of aortic valve replacement. Thorax 1970; 25: 339-346.
  2. Manouguian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. New operative technique. J Thorac Cardiovasc Surg 1979; 78(3): 402–12.

Comments

Submitted by Dusko Nezic on
Dear authors, The technique you have described is well known for more than 30 years, and it should be pointed out than these technique was described and published by Nunez and coauthors back in 1983 [1]. Best regards, Dusko Nezic, MD, PhD, FETCS Reference 1. Nunez L, Aquado MG, Pinto AG, Larrea JL. Enlargement of the aortic annulus by resecting the commisure between the left and noncoronary cusps. Tex Heart Inst J 1983;10(3):301-303.
Submitted by Guillermo Stöger on
Dear Dr. Duzco Nezic, even do we are aware of Nunez´s article, in this video we do not perform a Nunez approach, we do not resect the posterior commissure. The aim of this article was to show how we perform this technique. Thank you for your comment. Best regards.
Submitted by Dusko Nezic on
Dear authors, Although I am not able to open your video, whether you resect or just cutting through the posterior commisure and subaortic curtain, that is basically the same technique, therefore you shoul quoted Nunez's article. Although that is an excellent technique, you should mention the original author(s) in your report. Best regards, Dusko Nezic, MD,Phd,FETCS
Submitted by Tomas Heredia Cambra on
Congratulation for your work. I agree with your technique is so similar to the Nunez's approach too. Nevertheless, the video is so good and ilustrate step by step the pourpouses of this limmited aortic root enlargement. I have two questions for the authors: 1) How long have you enlarged the aortic annulus? In my experience we could increase only 2-3 mm de circunference, and this is no more than 1 mm on diameter. If you need a real enlargement of the root its necesary open de mitroaortic courtain, via Manouguian or Nick's aproach. 2) If you choose an stentless valve implant, don't you thinck that the EOA that you aim is practicaly the same in a simple way? Thanks and Best regards.
Submitted by Ricardo Marenchino on
Thank you Dr Heredia Cambra for yours comments. In our experience, the posterior enlargement let enhance the circunference of aortic annulus more than 2 o 3 mm. If you dissect the left atrium roof very low and you cut the left-non coronary interleaflet triangule into the mitroaortic curtain the aortic annulus really acquire more diameter and no always you open the left atrium. Usually we put in the patch 4 stitchs with pledget 3 x 7 mm. Two completely in the patch and the other in the junction between the patch and the aortic tissue. We think that opening left atrium the enlargement will be better but not always necessary. For the question two, may be that you are right but we don´t use this kind of valves in our department. Greeetings
Submitted by Ricardo Marenchino on
Thank you Dr Heredia Cambra for yours comments. In our experience, the posterior enlargement let enhance the circunference of aortic annulus more than 2 o 3 mm. If you dissect the left atrium roof very low and you cut the left-non coronary interleaflet triangule into the mitroaortic curtain the aortic annulus really acquire more diameter and no always you open the left atrium. Usually we put in the patch 4 stitchs with pledget 3 x 7 mm. Two completely in the patch and the other in the junction between the patch and the aortic tissue. We think that opening left atrium the enlargement will be better but not always necessary. For the question two, may be that you are right but we don´t use this kind of valves in our department. Greeetings
Submitted by Sandeep Sainathan on
I congratulate the Authors for the excellent video. There seems to be always a discussion as to whom these procedures should rightly be credited to. Posterior aortic root annular enlargement at the non-left sub commisural area, most of the time suffices the ability to upsize the prosthetic valve by one size, in order to avoid a PPMM. An extension into the the dome of the LA and aortomitral curtain is needed when one has to upsize by more than one size or there is also a component of LVOT narrowing which will negate the effects of a larger valve unless addressed. The extended procedure of course entertains the possibillity of more bleeding and mitral valvular dysfunction.

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