Isolated Pulmonary Leaflet Autograft: A New Solution for Aortic Valve Repair

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Leaflet replacement is one of the techniques used in aortic valve repair to preserve the valve. It is frequently performed when a leaflet is damaged or destructed due to conditions such as endocarditis, or deformed due to congenital problems. 

The main issue in leaflet replacement is the material used. The most common materials are autologous pericardium—either treated or untreated—and bovine pericardium. However, none of these options are ideal due to failures caused by degeneration and, in children, a lack of growth potential. 

On the other hand, the excellent long-term results of the Ross procedure have demonstrated that the pulmonary valve has excellent durability in the aortic position and has the potential for growth (1). The major mode of failure in the Ross procedure is root dilation, not the leaflet failure. 

Therefore, the authors designed a procedure to harvest only the leaflet and use it as an isolated autograft in the aortic position without disturbing the root and coronary arteries. 
 
Patient and Diagnosis 

The patient was a 6-year-old boy. An echocardiogram revealed a moderate-sized juxta-arterial, doubly committed ventricular septal defect (VSD) measuring 8 x 10 mms. Additional findings included moderate-to-severe aortic valve regurgitation and severe aortic insufficiency due to significant elongation, deformity, and prolapse of the right coronary cusp. 

Surgical Plan and Approach 

The patient was taken to the operating room for VSD closure and a possible aortic valve repair. Given the doubly juxta-arterial nature of the VSD, the surgical approach was through both the aorta and the pulmonary artery. 

The right coronary cusp was severely deformed, thickened, and elongated. The authors’ usual repair technique of central plication was not feasible for this leaflet, as its entire free edge was thickened and rolled back, making a satisfactory result unlikely. Therefore, the decision was made to replace the leaflet with the pulmonary valve leaflet autograft. 

Harvesting the Pulmonary Leaflet 

To excise the leaflet, approximately one mm of tissue was attached to the base on both the right ventricular muscular side and the pulmonary arterial side. The goal was to retain a  thickness of 1-2 mm of basal tissue; however, care was taken to avoid deep dissection into the muscular tissue to prevent damage to the septal artery. 

Excising the base of the leaflet partially detached the muscular and arterial tissues, which would later be rejoined when suturing the substitute leaflet into this area. The incision was advanced until the complete leaflet and its basal attached tissue was excised. The surgeons then proceeded to close the VSD through the pulmonary artery using a Gore-Tex patch in a standard fashion. 

Aortic Valve Leaflet Replacement 

The autografted leaflet was controlled with three sutures: two at the commissures and one at the midportion, marking the nadir of the leaflet to facilitate easier handling and better orientation for suturing. 

To implant the leaflet, the two commissures were fixed first to establish orientation. Suturing began at the midpoint at the nadir of the cusp and then proceeded bilaterally toward the commissures. The basal attached tissue provided a strong and secure suture line, as suturing to the delicate leaflet tissue itself is not safe and can cause tears at the needle points. The valve was evaluated and demonstrated an excellent configuration with good coaptation. 

Valve Function Testing 

To test the valve function, the aorta was closed, and cardioplegia was administered through the ascending aorta. A full and tense bulging of the aorta and the recovery of the cardioplegia solution through the coronary sinus confirmed acceptable valve function with no significant regurgitation. 

Reconstructing the Pulmonary Valve 

As the authors have gained more experience with right atrial tissue, a piece of the right atrial wall was selected for use. Other tissues, such as autologous (treated or nontreated) or bovine pericardium, are also suitable options for this location, which is, of course, less critical than the aortic valve. 

A piece of the right atrial wall was excised, and the muscle tissue was thinned. It was then similarly secured with three sutures at the corners and the nadir. It was trimmed to match the shape and size previously marked on the sheet. Suturing of this new leaflet began at the midpoint. With each stitch, the right ventricular outflow tract muscle, the pulmonary artery wall, and the new leaflet were taken together to close the gap created by the autograft excision. The configuration of the leaflet was examined and found to be satisfactory. 

Conclusion and Postoperative Findings 

The follow-up echocardiogram showed excellent function of the aortic valve with very trivial aortic insufficiency. The function of the autograft leaflet was satisfactory, as well as its coaptation with the other leaflets. 

Referring to the excellent long-term results of pulmonary leaflets in the Ross procedure, the pulmonary leaflet autograft may be an ideal substitute for aortic leaflet replacement. The procedure is reproducible and does not carry the possible long-term root complications associated with the Ross procedure itself. 

References

1. Aboud A, Charitos EI, Fujita B, Stierle U, Reil JC, Voth V, Liebrich M, Andreas M, Holubec T, Bening C, Albert M. Long-term outcomes of patients undergoing the Ross procedure. Journal of the American College of Cardiology. 2021 Mar 23;77(11):1412-22.

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