Valve-sparing aortic root replacement (VSRR) in grown-up congenital heart (GUCH) patients is a complex but feasible approach. The authors present their experience performing the David procedure in two adult patients with challenging congenital histories and failing neoaortic valves.
Case 1: Post-Arterial Switch Operation
An 18-year-old male presented with a history of arterial switch and coarctation repair in 2006. He exhibited severe bicuspid neoaortic valve regurgitation, neoaortic root dilation, and aortic arch kinking, with early signs of ventricular dysfunction.
The surgical approach involved a David procedure and neoaortic valve repair. Following the Lecompte maneuver, the pulmonary artery (PA) was identified anterior to the neoaorta. After transecting the right PA branch, deep proximal dissection of the neoaortic root was performed. A straight vascular graft was used for reimplantation. Due to tissue deficiency and tension, the right PA branch was reconstructed with a vascular graft. The patient had a steady recovery and was discharged on postoperative day 16 with only mild residual aortic regurgitation.
The one-year follow-up revealed moderate aortic insufficiency, which was attributed to the cheese wire effect caused by paracommissural plication. Nevertheless, significant left ventricular reverse remodeling was observed—with end-diastolic volume (EDV) decreasing from 216 mL to 186 mL—and the patient remained clinically stable.
Case 2: Post-Ross Procedure
A 31-year-old male with a history of a Ross procedure in 2009 presented with combined failure of the autograft and pulmonary conduit. Clinical findings included severe neoaortic regurgitation, root dilation, and conduit stenosis.
A David procedure, neoaortic valve repair, and right ventricular (RV)-PA conduit replacement were performed. Intraoperatively, a perforation in the right coronary cusp was identified and repaired using an autologous pericardial patch. Following the reimplantation of the neoaortic root into a straight vascular graft, the valve leaflets were plicated to ensure optimal coaptation. For the RV-PA reconstruction, a handmade conduit (Dacron graft with three Gore-Tex cusps) was utilized due to a lack of available homografts.
Because of generalized oozing, the chest was packed, and a successful delayed sternal closure was performed on day two. The patient was discharged on day 11. Follow-up echocardiography showed mild aortic regurgitation and a peak gradient of 17 mmHg across the conduit.
Closing Remarks
Valve-sparing surgery in GUCH patients is feasible and offers excellent postoperative results.
In expert centers, the outcomes of these operations are comparable to valve-sparing root replacement (VSRR) results in the standard patient population.
Meticulous and “deep” proximal dissection of the neoaortic root is a critical component of success. In the authors’ experience, central free-edge plication is the procedure of choice for ensuring optimal coaptation and long-term durability in aortic valve repair. Paracommissural plication is discouraged due to uneven stress distribution on the sutures and the risk of the cheese wire effect, which can lead to the development of late aortic insufficiency.
References
- Aicher, D., Langer, F., Adam, O., Tscholl, D., Lausberg, H., & Schäfers, H.-J. (2007). Cusp repair in aortic valve reconstruction: Does the technique affect stability? The Journal of Thoracic and Cardiovascular Surgery, 134(6), 1533–1539. https://doi.org/10.1016/j.jtcvs.2007.08.023
- Baliulis, G., Ropponen, J. O., Salmon, T. P., & Kaarne, M. O. (2016). Valve-sparing aortic root replacement in adult patients previously operated for congenital heart defects: an initial experience †. European Journal of Cardio-Thoracic Surgery, 50(1), 155–159. https://doi.org/10.1093/ejcts/ezv446
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