Deep Dive Into Aortic Surgery: Mini-Access CAVIAAR Procedure, Part 1: How to Assess Aortic Valve Competency 

Aortic root remodeling with external subaortic annuloplasty (CAVIAAR procedure) enables physiological movements of the aortic cusps within three symmetrically reconstructed neosinuses, thus preserving root expansibility with the interleaflet triangles (1). In addition, the external aortic annuloplasty prevents annular base dilatation. In Part 1, the author demonstrated how to assess the aortic valve competency by using several methods, including direct visual inspection, water injection, caliper measurement, and endoscopic dynamic testing (the snorkeling technique). Similar to the David procedure, CAVIAAR is an elegant operation. 

Mini Access 

A 5 cm midline incision was performed from the manubriosternal junction to the 3rd intercostal space. The incision was further developed through the subcutaneous fat onto the body of the sternum using a diathermy. An upper hemisternotomy to the left 4th intercostal space was performed using an electrical saw. The Yan Mini-Access Retractor was used. The thymic fat pad was removed to expose the ascending aorta, and the innominate vein superiorly. The pericardium was opened longitudinally. Three pericardial traction sutures were placed on each side.  

Mini-Access Aortic Root Remodelling With External Subaortic Annuloplasty 

Cardiopulmonary bypass was established via right femoral arterial and femoral venous cannulations. Under a low-flow condition, an atraumatic aortic cross-clamp was applied across the distal ascending aorta. Diastolic arrest was achieved with antegrade custodial cardioplegia delivery. The aorta was then transacted just proximal to the cross-clamp. The patient was cooled toward the 32 degrees centigrade. 

The aortic valve was assessed. Both coronary arteries were visualized, and the aortic root was carefully mobilized circumferentially. The left and right coronary buttons were prepared. Traction sutures were placed above the commissures and hitched up to provide an excellent exposure of the aortic valve. The aortic leaflets were tricuspid and in a reasonable condition. 

Subannular Dissection  

The aneurysmal portion of the ascending aorta was resected. External dissection of the aortic root was performed down to the base of the aortic annulus. The aortic root was then liberated from the pulmonary artery and infundibulum and from the roof of the left atrium to reach the subvalvular plane. The wall of the aortic sinus was totally removed, leaving a fringe of aortic wall measuring approximately 3 millimeters. The dissection was completed by freeing the subvalvular plane and the pulmonary infundibulum. Choice of external aortic ring diameter was based on internal aortic annular base diameter measured with Hegar dilators. 

Subvalvular Anchoring Suture Placement 

Six threads of CV4 pledgeted sutures were placed from the inside out as U stitches (width of 3 millimeters) circumferentially in the subvalvular plane. Three sutures were positioned 2 millimeters below the nadir of each cusp and three were placed at the base of the interleaflet triangles. Care was taken not to go deep in the membranous septum to avoid damaging the bundle of His lesion. 

Tailoring of the Valsalva graft 

The remodelling technique was performed using a Valsalva graft. The distal collar below the skirt of the graft was resected. The graft was scalloped to have symmetrical neosinuses using the linear demarcations on the bulging part of the graft. The heights of the scallops to suture the commissures were cut up to the transition point between circumferential and axial folds in the graft. The thickest premarked line was resected to facilitate the suturing of the prosthesis. A 30 millimeter Valsalva graft was chosen in this case. 

Aortic Root Remodelling 

The prosthesis was sutured following the sigmoid shape of the aortic annulus. The first stitch was knotted at the base of the sinus to facilitate suture tension. Stitches were passed very close to the annulus following leaflet insertion. This technique allows the preservation of the interleaflet triangles. 

Extra-Aortic Annuloplasty  

The six anchoring U stitches were passed through the inner aspect of the 30 millimeter Dacron graft ring. The ring was then descended around the remodeled aortic root. U stitches were tied to secure the ring outside of the aortic annulus. 

Coronary Reimplantation  

A Bovie electrocautery was used to create a hole to accommodate the left coronary button, which was anastomosed using a continuous 5-O running Prolene suture. The inferior border of the left coronary button was done first, using a right-hand forehand stitch to pick up the full thickness of the arterial wall. Once the superior rim was done, the suture was tied and cut. Similarly, the right coronary button was prepared and reimplanted using a continuous 5-O running Prolene suture.  

Aortoscopy 

Aortic valve competency could be assessed by using several methods including, direct visual inspection, water injection, caliper measurement, and endoscopic dynamic testing (the snorkeling technique). In the snorkeling technique, the aortic root was pressurized and tested by delivering a dose of antegrade crystalloid cardioplegia. The aortoscopic assessment of the aortic valve demonstrated that the right and noncoronary cusps were prolapsing slightly under pressure, which was corrected with two simple central cusp plication stitches (5-O Prolene sutures). 

Distal Aortic Anastomosis 

The distal aortic was measured and the reconstruction was performed with the 30 millimeter graft. The anastomosis was performed using a 3-O running Prolene suture. The suture was tied, the heart was deaired, and the patient was weaned from the cardiopulmonary bypass uneventfully. Postoperative echo demonstrated no evidence of aortic regurgitation, and the patient was discharged home uneventfully. 

References

1. Lansac E, Di Centa I, Vojacek J, Nijs J, Hlubocky J, Mecozzi G, Debauchez M. Valve sparing root replacement: the remodeling technique with external ring annuloplasty. Ann Cardiothorac Surg. 2013 Jan;2(1):117-23. doi: 10.3978/j.issn.2225-319X.2013.01.15. PMID: 23977568; PMCID: PMC3741820.

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