Homograft Replacement Twenty-Four Years After Persistent Truncus Arteriosus Repair

This video demonstrates a redo aortic root procedure and homograft replacement for a thirty-year-old woman who was diagnosed with PTA at birth. She also had surgical repairment and reconstruction of the right ventricular outflow track with a homograft when she was six. 

The computed tomography angiography (CTA) showed an aortic root aneurysm beneath her sternum and homograft calcification with severe stenosis. Also, the transesophageal echocardiogram (TEE) showed severe aortic insufficiency. 

A 5mm-diameter, 30-degree-angled endoscope was used to facilitate the retrosternal dissection, which gave us a clear vision for the safe use of the reciprocating saw. Dissection for adhesion was then performed after the conventional cardiopulmonary bypass was established to prevent major bleeding. After the aortic cross-clamp was applied and cardiac arrest occurred, dissection for adhesion continued, and a severe calcified homograft was taken out completely. The homograft valve was also calcified and degenerated and had lost its function. 

Next, a 25mm valve sizer was lowered into the right ventricular outflow. A pulmonary artery plasty was then performed to ensure an adequate diameter. 

After this, a David I procedure was performed in consideration of the patient’s fertility demand. The patient’s right coronary artery had an anomalous origin, which rises from the peri-commissure area of the aorta. The aortic root was dissected completely, and a typical type 0 bicuspid aortic valve was present. A 32mm prosthetic vascular graft was then used to replace the enlarged aortic root. A leaflet folding was performed to ensure an adequate coaptation height since the aortic valve ring was enlarged. The coronary artery anastomosis was reinforced by a pericardium patch. The valve testing and hemostasis examine were performed after the root reconstruction. Then, a bio-valved homograft conduit was utilized to replace the homograft. 

The postoperative TEE showed no obvious aortic insufficiency. 

References

1. Beckmann E, Martens A, Krüger H, et al. Aortic valve-sparing root replacement in patients with bicuspid aortic valve: long-term outcome with the David I procedure over 20 years. Eur J Cardiothorac Surg. 2020;58(1):86-93.
2. Christenson JT, Sierra J, Colina Manzano NE, Jolou J, Beghetti M, Kalangos A. Homografts and xenografts for right ventricular outflow tract reconstruction: long-term results. Ann Thorac Surg. 2010 Oct;90(4):1287-93. doi: 10.1016/j.athoracsur.2010.06.078 . PMID: 20868830 .
3. Huyan Y, Chang Y, Song J. Application of Homograft Valved Conduit in Cardiac Surgery. Front Cardiovasc Med. 2021 Oct 12;8:740871. doi: 10.3389/fcvm.2021.740871 . PMID: 34712711 ; PMCID: PMC8545902.

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