Modified Manouguian Aortoplasty in Patients With 16 mm Aortic Annulus

Small aortic root enlargement using the modified Manouguian technique for mechanical valve implantation is challenging, especially in the presence of calcified aortic annuli (1, 2). To augment the benefits of the modified Manouguian technique, the authors used a pericardial patch and performed a modification in the aortotomy incision - without entering into the left atrium or incising the anterior leaflet of the mitral valve. The small aortic root is then enlarged by using a tear drop shaped glutaraldehyde-treated pericardial patch into the subaortic curtain and the ascending aorta. Authors strongly recommend that the modified Manouguian technique using a pericardial patch aortoplasty is safe and feasible for patients who have a special consideration of patient-prosthesis mismatch, bioprosthesis, and short cross-clamp times.

Important Steps

1. A standard median sternotomy was performed, and cardiopulmonary bypass (CPB) was established, with standard ascending aorta cannulation and right atrial cannulation using a two-stage single venous cannula.
2. Venting from the left heart was performed through the right superior pulmonary vein.
3. The cross-clamp was applied to the ascending aorta and an oblique aortotomy was performed. Aortotomy was extended into the fibrous tissue between the noncoronary cusp and the left coronary cusp and onto the subaortic curtain.
4. The aortic valve was exposed and cold blood antegrade cardioplegia was given. However, the exposed aortic valve was excised and the annulus was measured carefully according to the patient's body surface area.
5. A modified Manouguian technique was performed without incising to anterior mitral leaflet or extending incision into the left atrium (2, 3).
6. The aortic root enlargement was performed using a tear drop-shaped, glutaraldehyde-treated pericardial patch. This pericardial patch aortoplasty was performed using a 5.0 polypropylene continuous suturing technique, starting at the rock bottom of the aortic incision and continuing up to 2.5 cm above the aortic annulus.
7. Then the aortic annulus was resized and a 21 mm size mechanical valve was used to replace the native aortic valve (preoperative Echo findings of aortic annulus was 16 mm).
8. 2.0 pledgeted polyester sutures were installed circumferentially around the aortic annulus, and suturing was completed from the outside into the patch area. The suturing of the prosthetic valve was done and then fixed into place.
9. The aortotomy incision was then closed with a 4.0 polypropylene suture in a continuous fashion using the pericardial patch.
10. After weaning from CPB, protamine was administered and the procedure was completed in a standard fashion. Weaning from CPB was uneventful.
11. The postoperative period was uneventful, and the patient is now doing well.

References

1. Manouguian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. New operative technique. J Thorac Cardiovasc Surg 1979;78(3):402–12.
2. Borowski A, Kurt M. A modification to the Manouguian aortoplasty for biological valve implantation in patients with small (< or =19 mm) aortic anuli--rationale and benefit. Tex Heart Inst J. 2008;35(4):425–427.
3. Pibarot P, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart 2006;92(8): 1022–29.

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