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Valve-Sparing Aortic Root, Ascending Aorta, and Aortic Arch Replacement

Thursday, September 3, 2015

A 73-year-old male presented with an ascending and aortic arch aneurysm, and aortic valve insufficiency. The patient had no coronaropathy, and normal left ventricle function. He had hypertension. The diameter of the ascending aorta was 57 x 60 mm, and the aortic arch diameter was 54 mm on preoperatory angio-CT scan. Aortography confirmed the irregular aortic walls, and the dilation of the ascending aorta and aortic arch. A valve-sparing aortic root, ascending aorta, and aortic arch replacement with debranching of the innominate trunk and left common was performed.

Clamping time was 157 minutes. Total cardiopulmonary bypass was 210 minutes, selective antegrade cerebral perfusion was 49 minutes, and visceral ischemia was 17 minutes. Postoperative ventilation time was 5 hours. The patient spent 23 hours in the ICU, and no major complications occurred. Postoperative echocardiogram did not show residual aortic insufficiency.

At the three-month follow-up exam, angio-CT showed normal patency of the branches of the innominate trunk and left carotid artery. Six months after the procedure, the patient was doing well. He was happy to be back running his restaurant in a small town on the outskirts of Vicenza.

Steps:

  1. After the sternotomy, the right axillary artery and the left femoral artery are cannulated.
  2. The innominate trunk and left carotid artery are prepared, and the patient is cooled.
  3. The circuit is prepared for selective antegrade cerebral perfusion. A number 30 Maquet platinum Hemasheid prosthesis is prepared.
  4. The aorta is clamped and retrograde infusion of cold hematic cardioplegia is started.
  5. The aneurysmal portion of the ascending aorta is removed.
  6. The valve leaflets are analyzed. 
  7. Each commissure is suspended by a U-shaped 4.0 polypropylene suture with a pledget.
  8. The coronary buttons are prepared.
  9. The aortic sinus wall is totally removed. A rim of approximately 5 mm of aortic wall is needed to suture the aortic valve to the Valsalva prosthesis.
  10. Three sub annular U-Sutures (in 3/0 Ethibon non absorbable polyester with pledget) are passed below each commissure.
  11. A Vascutek gel weave Valsalva prosthetic valve is prepared by partially removing the proximal collar. The diameter size of the Valsalva prosthesis is based upon adding 5 mm to the measurement obtained using Hegar’s dilator. (In this case the diameter was 25 mm, so a 30 mm valve was chosen.)
  12. Sub annular stiches are placed on the base of the Valsalva prosthesis.
  13. The Valsava graft is secured to the valve annulus. The stitches are tied so as not to stenose the annulus. This is done by tying the same Hegar’s dilator inside the annulus.
  14. The commissures are re-suspended at the level of the new sino-tubular junction.
  15. The valve remnants are fixed to the Valsava graft wall, corresponding to the new sinus. Three continuous 4/0 polypropylene running sutures are used, starting at the nadir of each leaflet towards the top of the commissure. The three sutures are then tied at the top of each commissure.
  16. Valve leaflet alignment and coaptation are checked.
  17. The coronary ostia are re-attached to the skirted portion of the Valsalva graft using a polypropylene 4/0 suture, with interposition of a thin layer of Teflon felt.
  18. The proximal anastomosis is performed using the polypropylene 4.0 between the Maquet platinum and Valsava vascular prosthesis. To ensure the correct angle is given to the prosthesis, the branches of the innominate trunk and left common carotid artery must be tilted toward the superior vena cava.
  19. Circulatory arrest is started once the patient's temperature reaches 26 °C.
  20. The innominate trunk is clamped. Perfusion of the right carotid artery through the right axillary artery cannula (8 ml/kg/min) is started.
  21. The opening is clamped, and visceral ischemia is started. The aortic arch aneurysm is resected up to 2 cm from the origin of the left subclavian artery.
  22. The supra aortic vessels are prepared (left carotid artery and innominate trunk).
  23. Selective antegrade left carotid artery (LCA) perfusion (5 ml/kg/min) is started. Perfusion pressure is monitored so that it remains above 60 mmHg.
  24. The vacuum vent line is inserted through a branch of the prosthesis to keep the operative area bloodless.
  25. The vascular prosthesis is resected.
  26. The distal anastomosis is performed between the vascular prosthesis and the aortic arch (running polypropylene 3-0 suture), with interposition of a thin layer of Teflon felt.
  27. The heart and vascular prosthesis are de-aired.
  28. Systemic and myocardial perfusion are reinstated through the femoral artery cannula. While selective antegrade cerebral perfusion is still running through the cannulas, the left carotid artery and the right axillary artery are placed.
  29. The proximal and the distal anastomoses are checked.
  30. The left carotid artery is debranched, using the n 8 branch of the platinum vascular prosthesis and a continuous polypropylene 5/0 suture. Selective antegrade perfusion of the left carotid artery is suspended.
  31. The innominate trunk is debranched, using the n 10 branch of the platinum vascular prosthesis and a continuous polypropylene 4/0 suture, with interposition of a layer of Teflon felt.
  32. Re-warming of the patient is started.
  33. The unused branches of the vascular prosthesis are ligated twice and cut. The stump is sutured with a continuous 4/0 polypropylene suture.

Comments

Very impressive case, well done. After reperfusion of the heart and viscera thru the femoral, did you have 3 seperate pumps - femoral, axillary and Left CC?
Excellent technique congrats! My opinion one could omit use of femoral a cannulation, go all the way with the axillary until arrest, then maintain cerebtal perf through axillary, do the distal aortic anastomosis and reinstitute antegrade peripheral perfusion through a side branch of the graft _while completing the neck branches _thus avoiding retro femoral perf and its potential complications. Once more congrats for an otherwise perfect procedure.

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