How I Do It: AVR With Patch Enlargement of the Aortic Root and Ascending Aortoplasty

We present our technique of aortic root enlargement and ascending aortoplasty during aortic valve replacement. Benefits of this technique include the ability to implant a larger valve prosthesis, as well as simultaneously reducing the size of a dilated ascending aorta, whilst avoiding reimplantation of the coronary arteries. We present a case of a patient, male, 67 years old, with a symptomatic severe AS. After median sternotomy and cannulation for bypass, an aortotomy is performed incorporating the non-coronary sinus of Valsalva, which is excised, leaving a 3mm rim of aortic tissue. A bovine pericardial patch is fashioned and used to replace the noncoronary sinus. The aortic valve prosthesis is implanted, the aortotomy is extended vertically on the anterior surface, and then excess aortic tissue is trimmed. The patch is used in continuity to perform a reduction aortoplasty. Usually, this allows for the implantation of one larger size aortic prosthesis than on initial sizing and reduces the ascending aorta diameter. This method has been adopted as a standard technique for aortic root enlargement in our institution. In summary, this is an easily reproducible and safe technique for enlargement of the aortic root and reduction aortoplasty which simplifies the operation and minimizes operative time.

Narrative:
This is a 67-year-old-male who has symptomatic aortic valve disease, referred for surgery.

He has a mildly dilated ascending aorta, measuring 4,0 cm. Has no coronary artery disease.

This image shows you the intraoperative measures of the ascending aorta.

This is the standing cannulation for Cardiopulmonary Bypass.

And the decision now is how we should manage this mildly to moderate ascending aorta dilatation.

So here you see the typical bicuspid valve. And we remove the valve completely using sharp dissection. And once we have done that we also remove the entering non-coronary sinus of Valsalva from commissure to commissure. This is view showing the sinus of Valsalva completely excised, prior the patch implantation.

So the non-coronary sinus of Valsalva is replaced by a bovine pericardium patch, which you see here. The patch is fashioned to match the sinus of Valsalva. The valve is sized and with this technique we are able to, at least, increase the valve size, up one size.

And this shows the sutures going in. These are large pledged 2-0 sutures around the annulus. And in the region of the patch we elevate the suture line about 0,5 to 1.0 cm to accommodate the valve. So the valve is than implanted and fits very well in.

We close the aortotomy starting from the left side and sew up until the midline of the aorta. At this point we stop and extend our incision superiorly up towards the cross-clamp. In addition, any excess of aorta is removed from the right side of the incision. In addition, we also remove a triangular section of ascending aorta in the surgeon side and complete the closure with the aortic patch.

Once we are off pump you can see the ascending aorta with a slightly smaller size and when we look at the post-operative transesophageal echo we also see that the ascending aorta is reduced down from its original size in about 1.0 cm.

This operation is very useful particularly in those cases where the ascending aorta is mildly/moderated dilated and cannot justify a full Bentall or ascending aorta replacement. The main advantage is to spare any implantation of coronary bottoms as well as have a reduced ischemic time.

References

1. Early and late outcomes following aortic root enlargement: A multicenter propensity score-matched cohort analysis. Tam DY, Dharma C, Rocha RV, Ouzounian M, Wijeysundera HC, Austin PC, Fremes SE. J Thorac Cardiovasc Surg. 2020 Oct;160(4):908-919.e15. doi: 10.1016/j.jtcvs.2019.09.062. Epub 2019 Sep 28.
2. Surgical Enlargement of the Aortic Root Does Not Increase the Operative Risk of Aortic Valve Replacement. Rocha RV, Manlhiot C, Feindel CM, Yau TM, Mueller B, David TE, Ouzounian M. Circulation. 2018 Apr 10;137(15):1585-1594. doi: 10.1161/CIRCULATIONAHA.117.030525. Epub 2017 Nov 22.
3. Early and late outcomes following aortic root enlargement: A multicenter propensity score-matched cohort analysis. Tam DY, Dharma C, Rocha RV, Ouzounian M, Wijeysundera HC, Austin PC, Fremes SE. J Thorac Cardiovasc Surg. 2020 Oct;160(4):908-919.e15. doi: 10.1016/j.jtcvs.2019.09.062. Epub 2019 Sep 28.
4. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, Evangelista A, Falk V, Frank H, Gaemperli O, Grabenwöger M, Haverich A, Iung B, Manolis AJ, Meijboom F, Nienaber CA, Roffi M, Rousseau H, Sechtem U, Sirnes PA, Allmen RS, Vrints CJ; ESC Committee for Practice Guidelines.

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