Redo AVR With an Extended LVOT Enlargement and a Patch for Ventricular Dissociation From the Aorta

The case presented involves a 34-year-old male who had a 21 mm St. Jude valve placed 10 years prior but now has a 4m/s gradient across this valve, which occurred as he continued to grow. Thus, he needed redo surgery to ensure that his indexed valve area was larger than 0.85cm²/m².  

The aorta was opened, and it was confirmed that the valve was perfectly normal, but it was too small for him.  

This video shows the valve being removed with a scalpel, and the valve was cut along the sewing ring. A suture was also placed to help lift the valve as it was being removed.   

A 21 mm On-X valve was selected, which was much larger than the 21mm St. Jude valve, but an extended left ventricular outflow tract (LVOT) enlargement was required to fit this into the thickened annulus.   

Thus, a Manougian-style operation was performed by debriding the annulus down to the anterior mitral leaflet and then cutting down to the anterior mitral leaflet.   

Additionally, the removal of the annulus caused dissociation of the base of the aorta from the left ventricle; therefore, a soft Dacron patch was used as a continuous pledget to reinforce this area as valve sutures were placed.   

The Dacron patch was secured with continuous 3.0 Prolene sutures, followed by the placement of the valve, and the aorta was then closed with the patch.  

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