Valve Sparing Root Replacement in a Transplanted Heart

The authors present the case of a 59-year-old man with a medical history of dilated cardiomyopathy and heart transplantation 10 years prior following aortic valve replacement and simultaneous implantation of a left ventricular assist device (LVAD). At the time of the transplant, the donor heart had a bicuspid valve and normal aortic diameters. During the follow-up CT angiography, the patient was diagnosed with a 55 mm aortic root aneurysm, with a normal ascending aorta and aortic arch. A transesophageal echocardiogram confirmed the previously known bicuspid aortic valve, Sievers Type I left/right, with no stenosis, no regurgitation, and normal left ventricular function. 
 
A median resternotomy was performed, and standard cannulation of the aorta and right atrium was established. Internal adhesions were moderate and easier to dissect than expected. After aortic clamping and the administration of blood cardioplegia in both antegrade and retrograde fashions, the aorta was transected just above the previous suture line. 

The aortic root was carefully dissected, starting at the main pulmonary artery, which is important for the mobilization of the left main coronary artery. Dissection continued toward the noncoronary sinus, approximately 3 mm below the aortic valve annulus. Extensive dissection is crucial to positioning the graft at the annulus level. Both coronary buttons were created in a standard fashion. Attention must be paid to the extensive mobilization of the coronary buttons to prevent distortion and kinking of both coronary arteries. 

Valve analysis showed no calcifications, no fenestrations, good leaflet mobility, and sufficient geometric height. A geometric height of at least 20 mm is considered a requirement for bicuspid valve-sparing root replacement to be successful. The annulus was measured at 26 mm, and a 30 mm straight vascular graft was selected. The primary suture line consisted of 2-0 pledgeted polyester sutures placed from inside to outside at the level of the aortic annulus. As is usual in the case of bicuspid valve surgery, nine subannular sutures were used. The subannular sutures were passed through the vascular graft, which was then parachuted into the root and gently tied down. The secondary suture line was performed with a 5-0 polypropylene suture, starting at the right sinus from the nadir to the commissure. The secondary suture line forms a U-shape for each sinus. 

The free margin was shortened by 6-0 polypropylene plication sutures to achieve an effective height of at least 8 mm. Effective height was measured using the Schaeffer caliper to assess for residual prolapse. 

Coronary button reimplantation was performed with a running 6-0 polypropylene suture, starting with the left coronary. The right coronary button was reimplanted higher, typically just below the neosinotubular junction. Distal anastomosis to the patient’s native aorta was performed using 30 mm vascular graft with a 4-0 polypropylene suture. 

After removing the cross-clamp, sinus rhythm was achieved, and the patient was weaned from cardiopulmonary bypass (CPB). Postoperative transesophageal echocardiography demonstrated no aortic regurgitation. 

The patient made an uneventful postoperative recovery and was discharged on postoperative day seven. 

At the one-year follow-up, the patient remained clinically well. A transthoracic echocardiogram revealed no aortic regurgitation, and CT angiography showed no evidence of anastomotic insufficiency. 

References

1. Schäfers HJ, Kunihara T, Fries P, Brittner B, Aicher D. Valve-preserving root replacement in bicuspid aortic valves. J Thorac Cardiovasc Surg. 2010 Dec;140(6 Suppl):S36-40; discussion S45-51. doi: 10.1016/j.jtcvs.2010.07.057. PMID: 21092794.
2. Forteza Gil A, Martinez-Lopez D, Rios Rosado E, Vera-Puente B. Aortic Valve Reimplantation in a Marfan Syndrome Patient. October 2024. doi:10.25373/ctsnet.27234300

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