BAV Repair and Aortic Root Replacement: Reimplantation

This video demonstrates a valve-sparing root replacement with a reimplantation technique in a fifty-two-year-old female with a dilated root aneurysm and a bicuspid aortic valve with mild aortic valve regurgitation. The procedure was done via median sternotomy.  

To start, routine cannulation for cardiopulmonary bypass was performed. Then, a left ventricular vent was inserted through the right superior pulmonary vein, cross-clamping was performed, and the heart was arrested in an antegrade fashion. The aorta was opened around the sinotubular junction. Then, root dissection was started and the right coronary button was isolated and suspended. This was followed by the left coronary button. The remaining part of the aorta was also transected. Suspension stitches were placed for an initial valve assessment. Then, dissection of the root began.  

The area between the aortic root and the right ventricular outflow tract was first dissected all the way down initially with Metzenbaum scissors and then with cautery at a low setting. This was done around the annulus to make sure it was below the nadir of both leaflets. A right-angle clamp was passed to make sure it was low enough.  

Next, a leaflet assessment was performed, and the prolapsed leaflet was plicated. This required two 6-0 Prolene sutures. A line between the two nadirs was drawn; the height between this line and the commissure corresponded to the graft size used. This was followed by subannular pledgeted suture placement. Then, two 4-0 pledgeted Prolene sutures were placed in the commissures for commissural suspensions. A total of eight subannular sutures were placed. A Valsalva graft was used, the lower two rings were trimmed, and all the subannular sutures were passed through the graft. The commissural suspension stitches were passed into the graft in preparation for sliding the graft down into the aortic root. Proper placement of the graft was ensured, and the graft was tied down. Then the commissures were suspended at the appropriate height.  

After this, the secondary hemostatic layer was done by starting two suture lines from the nadir to the commissure on each side of each leaflet. A water test confirmed a competent aortic valve. The left coronary button was anastomosed using a 6-0 Prolene suture. Once this was concluded, a cardioplegia needle was placed, the root was pressurized again, and the suture lines were tested. Distal anastomosis was performed in a regular fashion and was reinforced with a Teflon strip. This was followed by right coronary button anastomosis to the graft. 6-0 Prolene was also used for this anastomosis. A cardioplegia needle was placed in the graft for plegia and de-airing.  

Lastly, the clamp was removed, and the patient was weaned from cardiopulmonary bypass. Hemostasis was achieved, and an echocardiogram confirmed a competent valve with a good zone of coaptation. 

References

1. Ehrlich T, de Kerchove L, Vojacek J, Boodhwani M, El-Hamamsy I, De Paulis R, Lansac E, Bavaria JE, El Khoury G, Schäfers HJ. State-of-the art bicuspid aortic valve repair in 2020. Prog Cardiovasc Dis. 2020 Jul-Aug;63(4):457-464. doi: 10.1016/j.pcad.2020.04.010. Epub 2020 May 5. PMID: 32380025.
2. Karciauskas D, Mizariene V, Jakuska P, Ereminiene E, Orda P, Ordiene R, Vaskelyte JJ, Nedzelskiene I, Kinduris S, Benetis R. Early and long-term results of aortic valve sparing aortic root reimplantation surgery for bicuspid and tricuspid aortic valves. Perfusion. 2019 Sep;34(6):482-489. doi: 10.1177/0267659119831926. Epub 2019 Mar 1. PMID: 30823866.
3. Kayatta MO, Leshnower BG, McPherson L, Binongo JN, Lasanajak Y, Chen EP. Valve-Sparing Root Replacement Provides Excellent Midterm Outcomes for Bicuspid Valve Aortopathy. Ann Thorac Surg. 2019 Feb;107(2):499-504. doi: 10.1016/j.athoracsur.2018.08.011. Epub 2018 Oct 4. PMID: 30292845.
4. Sultan I, Komlo CM, Bavaria JE. How I Teach a Valve-Sparing Root Replacement. Ann Thorac Surg. 2016 Feb;101(2):422-5. doi: 10.1016/j.athoracsur.2015.12.035. PMID: 26777920.

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