Aortic Valve Reimplantation in a Marfan Syndrome Patient

This article is part of CTSNet’s Guest Editor Series, “Mastering Aortic Root Surgery—Learning From Top Surgeons”. Dr. Lorena Montes invited top cardiac surgeons from around the world to contribute clinical videos on various aortic root surgery techniques. 

The authors present the case of a 39-year-old woman with a diagnosis of Marfan syndrome and a mutation found on FBN1. She was on preventive treatment with atenolol and had no previous episodes of chest pain or dyspnea, maintaining a good functional class. During follow-up, she was diagnosed with a 49 mm aortic root aneurysm with mild aortic insufficiency and a 23 mm aortic annulus. 

The surgeons performed an aortic valve reimplantation (1), following the Stanford modification (2). A median sternotomy was performed and standard canulation on the ascending aorta and right atrium was established. The ascending aorta was resected and the aortic root was exposed. Careful dissection throughout the implantation zone around the left atrium and left ventricle was performed. This revealed the aortic annulus and the area where the subannular stitches would hold the Dacron graft. An extensive dissection was crucial to fixing the graft at the annulus level and avoiding the leaflets prolapse. The coronary arteries and aortic valve commissures were separated from the aneurysm. In this case, the aortic annulus was measured at 23 mm. The geometric height of each cusp was then measured: the noncoronary cusp was 23 mm, the right cusp was 21 mm and the left cusp was 19 mm.  

Then, 2/0 nonpledgeted sutures were inserted at the level of the aortic annulus to place the Dacron prosthesis at the desired annulus level. The annular diameter of a number 32 Dacron graft was reduced by three 2/0 Ti-Cron sutures at the level of each commissure, and then was fixed to the aortic annulus of the patient. The commissures were then reimplanted to the Dacron graft, carefully measuring the height and choosing the best orientation to achieve optimal coaptation. When this was achieved, the aortic root was carefully reimplanted with a running 4/0 Prolene suture. Then, both coronary ostia were reimplanted using a 5/0 Prolene suture. Before suturing the ascending aorta graft, the surgeons measured the effective height with a caliper to assure the best result. (3) If they detected any prolapse at this point, they would correct it with a cusp repair or a free margin plication. 

 After careful evaluation of the aortic valve, the surgeons performed an ascending aortic graft using a number 28 Dacron graft, which was sutured with a 4/0 Prolene suture.  

Then, the surgeons tested the aortic valve competence, by flowing cold blood through the graft. There was no left ventricle dilatation and strong aortic root pressure was achieved. Based on this, the surgeons decided to perform distal anastomosis to the patient’s native aorta with a 4/0 Prolene suture. After removing the cross-clamp, sinus rhythm was achieved, and the patient was weaned from the cardiopulmonary bypass with no incidences. Ischemic time was 94 minutes, and cardiopulmonary bypass time was 101 minutes. In the postoperative echo, no aortic regurgitation was found, with no residual prolapse and an effective height of 9 mm 

The postoperative course was uneventful, the patient was extubated during the first six hours and discharged from ICU after 72 hours. There were no complications during the admission and the patient was discharged home on postoperative day seven.

References

1. David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 1992;103:617–21; discussion 622.
2. Demers P, Miller DC. Simple modification of “T. David-V” valve-sparing aortic root replacement to create graft pseudosinuses. Ann Thorac Surg. 2004;78:1479–81.
3. Anand J, Schafstedde M, Giebels C, Schäfers H-J. Significance of Effective Height and Mechanism of Regurgitation in Tricuspid Aortic Valve Repair. Ann Thorac Surg. 2023;115:429–35.

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