Neoaortic Valve Repair With a Subannular Ring for Complex Trileaflet Prolapse After an Arterial Switch Operation

The authors present a case of a neoaortic valve repair with a HAART ring in a twenty-seven-year-old patient born with transposition of great arteries who underwent an arterial switch operation as a neonate. Indication for surgery was moderate-to-severe aortic insufficiency (AI), severe left ventricular (LV) dilation, and mild LV dysfunction. 

A redo median sternotomy was performed. The anterior (prior LeCompte) branch pulmonary arteries were mobilized out to the first order branches and controlled with vessel loops. The aorta and right atrium were cannulated and a left ventricular vent was placed via the right upper pulmonary vein. An aortic cross-clamp was placed and antegrade cardioplegia was delivered, both via root cannula and directly. 

The anterior pulmonary artery was transected proximal to bifurcation and the neoaorta was transected above the sinotubular junction. The aortic valve was trileaflet without fusion of the leaflets and there was a complex trileaflet prolapse. 

The valve was sized to a 21 millimeter annuloplasty ring (NCS 23 millimeter, LCS and RCS 21 millimeter) and subcommissural marks were placed 3 millimeters below. Cabrol-like horizontal mattress (3-0 pledget-supported Ti-cron) subcommissural sutures were placed and were passed through the corresponding posts on the ring. The ring was then brought down and secured. Additional looping sutures were then placed around the ring in each sinus. All sutures were tied down and knots were lateralized away from the leaflet. Central leaflet nodules were carefully excised. The leaflet lengths were longer than 32 millimeters and paranodular plications were done in each leaflet and the free edge length was equalized. The right coronary leaflet height was low, so additional plication was done to elevate this. The neoaorta was reanastomosed with continuous 3-0 polypropylene sutures, with a bovine pericardial buttress strip. The pulmonary artery was sutured together using running 4-0 polypropylene. 

The patient separated from CPB in NSR. Post-op TEE showed trivial-to-mild AI and low-normal biventricular function. The patient was extubated in the operating room and post-operative convalescence was unremarkable. The patient was weaned from inotropes on postoperative day 1 and was discharged on postoperative day 4. 

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