Redo Sternotomy with David VI Valve-Sparing Aortic Root Replacement in an 18-Year-Old

The patient is an eighteen-year-old who underwent previous sternotomy for closure of a perimembranous ventricular septal defect and resection of subaortic membrane and presented with progressive aortic root dilation. He had strong family history of aortic dissection; therefore, surgery was recommended.

Preoperative studies showed no residual intracardiac shunt and competent aortic valve with good biventricular function. The aortic root was dilated with a normal-sized ascending aorta.
Through a repeat median sternotomy and aortic and bicaval cannulation, cardiopulmonary bypass was initiated without difficulty and the patient stayed at normothermia. Cardioplegic arrest was achieved via direct antegrade cardioplegic. The aortic root was completely mobilized and the ascending aorta was transected. Next, the aortic valve was evaluated to be tricuspid with normal looking leaflets. The left, followed by the right coronary artery buttons were harvested and mobilized. 

Then, all dilated aortic sinuses of Valsalva tissues were resected, leaving a 4-5 mm rim for future reimplantation of the aortic valve. A 28 mm Valsalva graft was used for reimplantation. Sizing determination was based on the left/noncoronary commissural height. Surgeons tailored the graft by cutting the majority of the skirt and creating a notch in the area of the right ventricular outflow tract and interventricular septum. The aortic valve was then reimplanted inside the Valsalva graft. A total of six interrupted pledgeted 2-0 Ethibond sutures were placed in a horizontal mattress fashion to create the first suture line. The commissures were then secured to the graft with three interrupted pledgeted 4-0 Prolene sutures that were placed in a horizontal mattress fashion. 

The second suture line, or hemostatic line, was then created using running 4-0 Prolene sutures in each of the three sinuses of Valsalva. The valve competence was tested with saline. The left, followed by the right, coronary artery buttons were then reimplanted in the middle of the corresponding sinus of the graft and secured using running 5-0 Prolene sutures. The distal aortic anastomosis was then completed with running 4-0 Prolene sutures, supported with a strip of bovine pericardium. The heart was then deaired and the aortic cross-clamp was removed.

The patient was then ventilated and weaned off cardiopulmonary bypass without difficulty. Once a transesophageal echocardiogram confirmed satisfactory results, all cannulas were removed and cannulation sites were secured. The rest of the procedure and chest closure was then completed in the standard fashion.

The aortic cross-clamp and cardiopulmonary bypass times were 110 and 131 minutes respectively. The patient was extubated in the operating room and received no transfusions. He was discharged four days later.

A follow-up echocardiogram and CT scan showed no evidence of aortic regurgitation and good biventricular function. The patient continued to do well one year postoperatively.

References

1. Chirichilli I, Scaffa R, Irace FG, Salica A, Weltert LP, D'Aleo S, Chiariello L, De Paulis R. Twenty-year experience of aortic valve reimplantation using the Valsalva graft. Eur J Cardiothorac Surg. 2022 Dec 29:ezac591.
2. Patel ND, Williams JA, Barreiro CJ, Bethea BT, Fitton TP, Dietz HC, Lima JA, Spevak PJ, Gott VL, Vricella LA, Cameron DE. Valve-sparing aortic root replacement: early experience with the De Paulis Valsalva graft in 51 patients. Ann Thorac Surg. 2006 Aug;82(2):548-53

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