When autograft dilation and neo-aortic valve regurgitation develop late after the Ross procedure, there are two surgical options: aortic root replacement with mechanical or biological prosthesis, or aortic valve preservation (valve-sparing aortic root replacement (VSRR)).
This video shows an adolescent male who presented with aortic root enlargement and severe aortic regurgitation five years following a Ross procedure. The ascending aorta, densely adherent to the sternum, was lacerated on reentry. Bleeding was controlled by re-approximation of the sternal edges. Femoral cannulation was expeditiously accomplished, but given the severity of aortic valve regurgitation, the patient continued to eject on cardiopulmonary bypass. An apical left ventricular vent was inserted via a limited left anterior thoracotomy, and instituted rapid cooling. As soon as the heart fibrillated, the sternotomy was rapidly completed, and control of the distal ascending aorta was obtained within six minutes of circulatory arrest. The heart was arrested with an antegrade intra-coronary infusion of cold blood cardioplegia.
The neo-aortic valve appeared intact, and the aortic regurgitation was deemed as secondary to the splaying of the sinotubular junction. The authors thought that an aortic root replacement with a mechanical prosthesis was not ideal. Proceeding with a VSRR procedure was also thought ill-advised because of its inherent complexity, as the authors were hopeful that the myocardium had not been injured by left ventricular distension. It was decided to downsize the sinotubular junction in the hope that competency of the aortic valve would be restored.
A 34 mm Dacron conduit was interposed between the sinotubular junction and the distal ascending aorta. The patient was weaned from cardiopulmonary bypass after a cross-clamp time of 31 minutes, with trivial neo-aortic valve regurgitation. By the following morning, the patient was on minimal ventilator settings, neurologically intact, and had excellent hemodynamic performance and cardiac function. The patient was then returned to the operating room, where a VSRR was performed. The VSRR yielded trivial neo-aortic valve regurgitation at completion of the procedure.
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6 Comments
What imaging did you use to estimate the proximity of the heart and outflow tracts to the sternum as a pre-op investigations?
When would you go on peripheral CPB and cool (deep hypothermia and TCA) before sternotomy?
We use chest CT with contrast to evaluate clearance between the sternum and anterior surface of the heart and great arteries in planning reoperations. MR in our experience tends to underestimate the distance between the two (and raise fear unnecessarily). In this case, the preoperative CT suggested there was more than adequate separation to permit safe re-entry. Nevertheless, we exposed the femoral vessels in case they were needed urgently. In the absence of aortic regurgitation, we would have instituted cardiopulmonary bypass and decompressed the heart, and perhaps even cooled and induced hypothermic arrest where aortic injury was likely. This patient had severe AR so cooling and deep hypothermic arrest before sternotomy was not an option because of the hazard of LV distension. Duke Cameron
Thank you very much for your very clear answer.
In our practice we also use CT in trying to estimate the distance and existence of a tissue plane between the sternum and heart/outflow tracts.
If CT suggests that heart/outflow tracts appear very close to the sternum then MRI images can be used, to check if the heart/outflow tract is immobile and appears ‘’stuck and hanging’’ at the point closest to the chest wall. Cardiac cath images can be useful for this as purpose, if MRI is not available.
If the RV/RVOT is near the sternum, then we will dissect free Fem art/Fem vein, prior to sternotomy.
If imaging suggests that a RV/RVOT is in danger of injury, along redo sternotomy then heparinization and peripheral CPB will be established prior to redo-sternotomy.
If the pulmonary venous atrium, or systemic ventricle (TCPC patient) or the Aorta (especially if dilated or if a homograft is been used in the aortic position) or the RCA (or grafts) is very close to the sternum, then we will establish peripheral CPB and cool. For this purpose, Fem art/Fem vein or Axillary art conduit/Fem vein, or Carotid Art conduit/Femoral vein have been used. Sternotomy will take place under TCA on 18 degrees Celsius.
The Ventricular distension will be accessed constantly by continues TEE imaging along cooling. If significant AR is there, then we have found useful to do massage compressions on the chest wall, which will empty the ventricle and will not allow severe distension at any point along cooling. Apical vents, inserted though mini-anterolateral thoracotomies have been used as well. George Belitsis
When AR is truly severe, no technique of LV venting is going to completely decompress the LV, and much of the CPB perfusate will run off into the vent, leading to systemic hypoperfusion and poor cooling. I agree that lesser degrees of AR can be managed by the techniques you mention (and we have used them all) but beware severe AR.
Thank you very much Prof for taking the time and replying. I will remember your advice regarding truly severe AR. With Respect, George Belitsis (Senior Fellow in Cardiac Surgery, Royal Brompton and Harefield NHS Trust, London, UK).
Great case – one question… do you place interrupted mattress sutures in the proximal suture line, in addition to the three pledgeted mattresses that you show in the video? thanks