Deep Dive Into Aortic Surgery: Mini-Access David Procedure—Endoscopic Assessment of Valve Competency 

Valve sparing root replacement requires meticulous surgical techniques to restore aortic valve function. Several methods have been used to assess aortic valve competency post reconstruction, including visual inspection, water injection, and measurement of effective heights. However, it remains difficult to evaluate leaflet coaptation and degree of cusp prolapse when the aortic root is not pressurized. In this video presentation, a dynamic assessment of aortic valve competency is achieved by positioning an endoscope inside of a newly reconstructed aortic root, while pressurizing the root with crystalloid cardioplegia. Although the aortic valve was competent, the aortoscopic assessment clearly demonstrated that the right coronary cusp was prolapsing slightly under pressure. It remains unknown if this degree of subclinical prolapse would lead to further deterioration of aortic valve function over time. The prolapsed cusp was easily corrected with a central cusp plication stitch. 

Preparation 

A 5 cm midline incision was performed from the manubriosternal junction to the third intercostal space. A mini sternotomy was performed using an electrical saw. Three pericardial traction sutures were placed on each side. A minimally invasive sternal retractor was used. Cardiopulmonary bypass was established via the right femoral artery and vein.  

Mini Access David Procedure  

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 32 degrees. 

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 fashioned. Traction sutures were also placed above the commissures and hitched up to provide excellent exposure of the aortic valve. The aortic leaflets were tricuspid and in reasonable condition.  

A David procedure was performed. The aortic root was mobilized circumferentially. Six 2-O pledgeted subannular sutures were placed below the nadirs and the commissures. The aortic root was sized and a 30-mm Vascutek Gelweave Valsalva graft was chosen and the collar was trimmed. The subannular sutures were passed through the collar portion of the Valsalva graft. The commissures were positioned inside of the graft and hitched up to check for coaptation depth. The sutures were clipped and cut, and the sutures were tied one by one around the subannular level. The haemostatic layer was achieved by using 4-O running Prolene sutures that incorporated the remnant of the aortic wall and the Valsalva graft.  

Bovie electrocautery was used to create a hole for the left coronary button, which was reimplanted using a 5-O running Psuture. Similarly, the right coronary button was prepared and reimplanted using a continuous 5-O running Prolene suture.  

Aortoscopy 

The aortic root was pressurized and tested by delivering a full dose of antegrade cardioplegia. The endoscopic assessment of the aortic valve demonstrated that the right cusp was prolapsing slightly under pressure. This was realigned with a simple central cusp plication stitch using a 5-O Prolene suture. 

Distal Aortic Anastomosis 

The distal aortic was measured and the reconstruction was performed with the 30 mm graft. The anastomosis was performed using a 3-O running Prolene suture. The suture was tied, the heart was de-aired, and the patient was weaned from the cardiopulmonary bypass uneventfully.  

Completion 

Hemostasis was carefully checked, and protamine was given to reverse the Heparin effect. Two 24 Fr soft drains were inserted. Three double stainless steel wires were passed to secure the superior portion of the sternum. Two No. 1 Vicryl sutures were used to close the fascia and the subcutaneous fat. The skin was closed with 4/0 Monocryl sutures.  

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