Aortic Valve Repair Using Rigid Internal Ring Annuloplasty Device

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The patient was a 31-year-old male with a history of a bicuspid aortic valve, diagnosed at age 13, who had mild aortic insufficiency, an aortic root aneurysm, and ascending aortic dilation. The patient presented for elective surgical intervention, which included a valve-sparing root replacement (David procedure), aortic valve repair using a rigid internal ring device, and hemiarch replacement. 

The patient's past medical history was significant for asthma and vitamin D deficiency, with a surgical history of Tommy John surgery. The family history was unremarkable, with no known aortic disease and negative genetic testing. The social history included rare alcohol consumption and no history of smoking or illicit substance use. 

The patient was on losartan 50 mg daily and denied symptoms such as chest pain, back pain, or shortness of breath. 

As part of his workup, he underwent magnetic resonance angiography. 

The patient had a bicuspid aortic valve, Sievers type I right-left cusp fusion, with unrestricted opening and mild eccentric regurgitation. Imaging also revealed dilation of the aortic root, measuring up to 50 mm, with the ascending aorta mildly dilated to 41 mm at the sinotubular junction and 39 mm at the level of the pulmonary artery. The patient had normal biventricular size and preserved global systolic function. 

The patient also underwent congenital transthoracic echocardiography, which revealed mild aortic regurgitation without evidence of stenosis. Imaging revealed dilation of the ascending aorta measuring 39 mm and dilation of the aortic root measuring 46 mm. The left ventricle was normal in size and systolic function, with an ejection fraction of 66 percent. There was trace mitral and tricuspid regurgitation with normal right ventricular function. 

Arterial cannulation was performed in the distal ascending aorta, with a dual-stage venous cannula placed in the right atrial appendage. A retrograde cardioplegia cannula was positioned in the coronary sinus, and a left ventricular vent was placed via the right superior pulmonary vein. A root vent was positioned in the ascending aorta. The aorta was then cross-clamped, and 1 liter of del Nido cardioplegia was delivered both antegrade and retrograde. 

The aortic root was carefully dissected, and the ascending aorta was then transected. The native valve was identified as bicuspid with a Sievers 1 right-left cusp fusion. The coronary buttons were detached from the aortic root, and aortic root aneurysmal tissue was removed. 

Using spherical HAART sizers, the leaflet free edge length was assessed to determine the appropriate angular dimensions for effective coaptation. Sizing was based on the nonfused leaflet free edge length and intercommisural distance. Based on the measurements, a 25 ring was selected. 

While the leaflets were structurally intact, the thickened free margin of the fused leaflet was shaved. 

Six nadir stitches were placed below the annulus. These subannular sutures secured the annulus from inside out. 

The device was released by cutting the retention suture in one place and advancing the device off the holder with closed forceps. 

The ring was lowered into position and secured with looping sutures. These sutures began above the annulus near the sinus wall, passed deeply into the annular tissue, and exited below the device, approximately 2-3 millimeters deep to the leaflet-aortic junction. Care was taken to ensure that there was no contact between the device and the leaflets. The needle was retrieved below the device and brought centrally to loop the ring before being passed again below and above the annulus near the sinus wall. 

Three looping sutures were placed in each sinus to ensure firm device-to-annulus apposition. It is important to note that in bicuspid aortic valve repair, leaflet tissue can sometimes be thick and challenging to distinguish from the annulus. 

For the David procedure, a 30 mm Valsalva graft was utilized. The annular sutures were pulled through the graft, and 3-0 Ethibond sutures were used to secure each post of the HAART ring through the subcommissural triangles. The posts were first tied for stability to ensure precise positioning and effective coaptation of the repaired valve. 

The hemiarch repair was performed using a 28 mm Dacron graft with a 10 mm sidearm. Hypothermic circulatory arrest was initiated using the Shaggy protocol to minimize embolic risk. Retrograde cerebral perfusion was provided for five minutes, followed by the initiation of arterial inflow via the sidearm graft. 

The cardiopulmonary bypass time was 129 minutes, and the cross-clamp time was 106 minutes. 

Intraoperative transesophageal echocardiography demonstrated a successful repair, with no evidence of aortic valve stenosis or regurgitation. 

Postoperatively, the patient progressed well. Shortly after arriving at the cardiothoracic intensive care unit, the patient was successfully extubated to a nasal cannula. On postoperative day one, vasoactive medications were discontinued, lines were removed, and the patient was transferred to the stepdown unit. On postoperative day two, pacing wires were removed, and on postoperative day three, the first mediastinal drain was discontinued. By postoperative day five, the second mediastinal drain was removed, and the patient was discharged home in stable condition. 

Before discharge, a congenital transthoracic echocardiogram was performed, which showed no evidence of aortic stenosis or regurgitation on spectral or color Doppler imaging. 

A 25 HAART ring was selected based on the leaflet dimensions and intercommissural distance. The ring was placed with six nadir stitches and secured with looping sutures to ensure firm apposition while avoiding leaflet contact. The most common mode of failure for a David procedure is graft slippage above the annulus, but this approach effectively prevented it by stabilizing the annulus. 3-0 Ethibond sutures were used to secure each post of the HAART ring through the subcommissural triangles. 

References

1. Jasinski M, Rankin S. Aortic valve annuloplasty with the HAART geometric ring and ascending aorta replacement. Multimed Man Cardiothorac Surg. 2018;2018:10.1510/mmcts.2018.024. Published 2018 May 2. doi:10.1510/mmcts.2018.024 PMID: 29750406

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