A Tailored Approach to Supra-Commissural Left Coronary Ostium During Valve-Sparing and Tricuspid Aortic Valve Repair

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Aortic valve repair and valve-sparing aortic root replacement are excellent approaches to treating aortic root aneurysm and severe aortic regurgitation when valve repair is feasible (1, 2). Congenitally abnormal supra-commissural coronary ostia are rare conditions; however, they can pose challenges when performing a valve-sparing procedure (3-5). 

This video aims to suggest a tailored approach to address this complex scenario. The technique is presented through an emblematic case of a 25-year-old male with symptomatic severe aortic insufficiency and congenitally abnormal supra-commissural left coronary ostium in a tricuspid aortic valve. The patient experienced a transient ischemic attack one year before the surgery without any consequences (Logistic EuroSCORE 1.51 percent and EuroSCORE II 0.56 percent). 

The surgery consisted of valve-sparing aortic root surgery and aortic valve repair. The operation was performed via a median sternotomy under normothermic cardiopulmonary bypass (CPB), established through the ascending aorta and right atrium. After initiating CPB, the aorta was cross-clamped, and intermittent warm blood cardioplegia was administered, first through the aortic root and subsequently via selective coronary cannulation. Left heart decompression was achieved through the right superior pulmonary vein. 

Transverse aortotomy exposed a tricuspid aortic valve with small cusps, thickened free margins, and no calcifications. All cusps were mobile. Prolapse of the left and noncoronary cusps was evident, attributed to a low-lying commissure between them. Importantly, the left main coronary ostium was found just above this commissure. 

Geometric cusp heights measured 17 mm for the right coronary cusp, 15 mm for the left coronary cusp, and 17 mm for the noncoronary cusp, while the free margin lengths were 36 mm for the right coronary cusp, 32 mm for the left coronary cusp, and 36 mm for the noncoronary cusp. 

Circumferential dissection was performed down to the cusp nadirs. The ascending aorta was resected, preserving the native valve. The right coronary ostium was isolated as a button, while the left supra-commissural ostium was preserved along with the commissure between the left and noncoronary cusps. 

The 28 mm graft used for the root replacement was cut accurately to correspond with the supra-commissural coronary ostium, allowing it to settle inside a hole at the top of the incision without distortion. Felt-reinforced 2-0 Ticron stitches at the level of the ventricular-aortic junction embraced the abnormal coronary ostium. These stitches were placed on either side of the vertical incision on the graft and were then tied to close the gap on the Dacron graft, with one of the two arms of the suture passed under the coronary trunk to join the other arm.  

Moreover, reimplantation of both the valve and the misplaced ostium was performed, following their contours using three 4-0 polypropylene running sutures. In addition, shaving and plications of the aortic cusps were performed. The right coronary artery was reimplanted using a 5-0 polypropylene running suture. Finally, an external aortic 2-0 Gore-Tex annuloplasty was completed (6). Distal anastomosis was completed between the graft and the ascending aorta using a 4-0 polypropylene running suture. 

The patient was weaned off CPB uneventfully, remaining in sinus rhythm without inotropic support. Intraoperative transesophageal echocardiography showed minimal aortic regurgitation, competent mitral valve, and good coronary flow. 

Two pericardial drains and one Jackson-Pratt drain were placed. Temporary pacing wires were attached to the right atrium and right ventricle. The sternum was closed with seven steel wires, and the chest was closed in three layers with a resorbable intradermal running suture. 

Total cardiopulmonary bypass time was 129 minutes, and the total cross-clamp time was 118 minutes. Postoperative echocardiography showed a good result of the surgery. The patient experienced a full recovery from the intervention. 

The left congenitally abnormal supra-commissural coronary ostia should not be a contraindication for valve-sparing aortic root surgery, as this condition could be managed with a modified technique for graft implantation used in root replacement. Further studies are required to verify the long-term outcomes of this type of surgery in a larger cohort of patients. 

References

1. David T. E., Feindel C. M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. The Journal of thoracic and cardiovascular surgery, 1992, 103.4: 617-622.
2. De Kerchove L., Nezhad Z. M., Boodhwani M., El Khoury G. How to perform valve sparing reimplantation in a tricuspid aortic valve. Annals of cardiothoracic surgery, 2013, 2.1: 105.
3. Hechadi J., De Kerchove L., Tamer S., El Khoury G. Modified valve-sparing reimplantation technique for para-commissural coronary ostia. European Journal of Cardio-Thoracic Surgery, 2014, 45.5: 937-938.
4. Sheikh A. M., David T. E. Aortic valve-sparing operations: dealing with the coronary artery that is too close to the aortic annulus. The Annals of thoracic surgery, 2009, 88.3: 1026-1028.
5. Matsuda H., Ichikawa H., Iwai S., Takahashi T. Modified aortic root remodeling for annuloaortic ectasia with abnormal coronary take-off. The Annals of thoracic surgery, 2002, 74.5: 1687-1689.
6. Schneider U., Aicher D., Miura Y., Schäfers H. J. Suture annuloplasty in aortic valve repair. The Annals of thoracic surgery, 2016, 101.2: 783-785.

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