Operative Strategy. Operative Technique

Transcription

1 Domingo Liotta, M.D.; Christian Cabrol, M.D; Miguel del Rio, M.D; Armando Diluch, M.D; Adriano Malusardi, M.D. Figure 11 Acute dissected aortic root and ascending aorta with valvular regurgitation. -Replacement of ascending aorta. -Reattachment of the commissures The aorta has been transected approximately 1 cm distally to the sinotubular junction. 1, 3- Pledgeted sutures are resuspending the commissures. 2- First a 7-0 Prolene suture has been placed through each nodule of Arantius and tied. The simple maneuver helps to evaluate on the appositional relationship of the aortic leaflets once the commissures are reattached. The arrows indicate the nadir points of aortic cusps. valve graft. The coronary ostia were implanted in the valved-conduit. Moreover, 2 patients with Marfan s disease out of the 16 implanted with composite valve graft underwent MVR with a mechanical prosthesis. In addition, a middle-aged woman with dissection of the ascending aorta and a rupture of the mitral valve after a car accident underwent MVR with mechanical prosthesis and a separate ascending aorta repair. CHRONIC ANEURYSM FROM SINOVENTRICULAR JUNCTION (SVJ) TO THE ROOT OF THE INNOMINATE ARTERY. A chapter with multiple variations due to the interrelation of anatomical and functional factors: a)-the fibrous components of subaortic outflow tract, b)-the leaflets of the aortic valve, c)-the ostia of coronary arteries and coronary flow, d)-the sinotubular junction, and e)-the ascending aorta. Chronic Aneurysm of the Aortic Root and the Ascending Aorta with normal aortic valve In preoperative studies and during direct observations in surgery the aortic root appeared asymmetrical, (Figs. 21, A-B).The most commonly affected sinus of Valsalva is the noncoronary sinus, followed by the right sinus. Dilatation of the left coronary sinus is not so frequent in the middle-aged patient with medial degenerative atherosclerosis disease. Normal or mildly dilated left coronary sinus needs not to be replaced. On the contrary, dilatation is almost symmetrical in the three sinuses of Valsalva in Marfan s disease patients. Aortic asymmetry can be exceptionally found in young patients with evidence of Marfan s disease. Once observed, chronic dissection can be suspected, (Fig. 22). Operative Strategy -Preservation of normal aortic leaflets. -Adjustment of the fibrous components of the subaortic outflow tract. -Replacement of aortic sinuses. -Adjustment of the sinotubular junction. -Replacement of the ascending aorta. Operative Technique The aortic root must be dissected down to reach the attachments of the left and right atria. The pulmonary artery should also be exposed. These anatomical structures should be protected while the surgeon places the sutures through the subaortic outflow tract. The base of the aortic root (annulus) is measured by using Hegar dilators. A normal diameter for each patient could be as follows: 24 mm for the average adult male, 27 mm for a very large male or female, 23 mm for the average adult female. Then, a 24 to 28 mm-diameter Dacron graft is selected. 294

2 REPAIR OF THE AORTIC ROOT, THE ASCENDING AORTA AND THE SUBAORTIC OUTFLOW TRACT 25 Figure 12 A mild prolapsing leaflet can be fixed with a simple technique. It is illustrated in the drawings A and B (see text for further explanation). The central spots indicate the noduli of Arantius. A 7-0 Prolene suture is passed and tied through each nodule to have a better visual inspection of the three aortic leaflets appositional relationship (30% to 50% of cusp area). Reprinted, with permission, from Liotta D, Cabrol C, Cooley DA, La chirurgie cardiaque d aujourd hui (Today Cardiac Surgery), 1984,Paris, Maloine ed: p.141. Figure 13 Ascending Aorta and Aortic Root Dissection Replacement of the Ascending Aorta and the noncoronary Sinus -Left drawing:the Dacron graft is trimmed off, creating an extension to form a neosinus that will replace the noncoronary sinus of Valsalva. -Right drawing: Replacement of ascending aorta and of noncoronary sinus. Figure 14 Ascending Aorta and Aortic Root Dissection Replacement of Ascending Aorta and of noncoronary and right coronary sinuses of Valsalva. Left drawing: The Dacron graft is trimmed off creating a separate extension that will form two neosinuses. 1-Dacron graft straight segment to be sutured to the left coronary sinus 2-Dacron graft extension to be sutured to the noncoronary sinus. 3-Dacron graft extension to be sutured to the right coronary sinus. Right drawing: Replacement of ascending aorta and of noncoronary and right coronary sinuses. 1-Posteromedial segment of the sinotubular junction sutured. 295

3 Domingo Liotta, M.D.; Christian Cabrol, M.D; Miguel del Rio, M.D; Armando Diluch, M.D; Adriano Malusardi, M.D. Figure 15 Adjustment of Sinotubular Junction The three commissures act as stay sutures to be spatially placed 120 apart each other in the Dacron graft. The arrows indicate the nadir points of aortic cusps. A-Left coronary sinus: posteromedial segment of sinotubular junction. Figure 16 Aortic Root and Ascending aorta Dissection Aortic root dissection of noncoronary and right coronary sinuses aggravated by a dissected right coronary artery. -The ostium of the right coronary artery is oversewn and its proximal segment is bypassed with a saphenous vein graft. 1- The commissure of noncoronary and right coronary sinuses is resuspended. 2- Dissection of the proximal segment of the right coronary artery. The dissected artery is observed at the bottom of the right sinus crevice. The spots indicate the nadir points of aortic cusps. Figure 17 Aortic root, ascending aorta and right coronary artery dissection -Replacement of ascending aorta and dissected sinuses. Bypass of the right coronary artery with a saphenous vein graft. Reprinted, with permission, from Liotta D, Cooley DA, Cabrol C, Cirugia Cardiaca y Cardiologia, Buenos Aires, Inter-Medica ed, l985: p Figure 18 Dissection of the ascending aorta with a tear extended near the ostium of the left coronary artery. In two patients of our series of 131 surgically treated for acute dissection of the ascending aorta, a tear in the vicinity of left coronary ostium was fixed with two interrupted 5-0 Dacron pledgeted sutures. The patients did well. 296

4 REPAIR OF THE AORTIC ROOT, THE ASCENDING AORTA AND THE SUBAORTIC OUTFLOW TRACT 25 A B C Figure 19-A Reattachment of the coronary ostia by the button technique A-The sinuses walls are cut approximately 5 mm around the ostia to be mobilized as buttons. Next, a hole is cut in the graft exactly opposite the ostia. The dissection of the coronary arteries should be carefully done. A soft silastic catheter introduced in the main trunk may help to dissect off the coronary arteries in difficult cases. B-The sinus wall cut around the ostium is sutured to the graft employing 4-0 or 5-0 Prolene suture.the suture line starts at the 3 or 4 o clock position and runs in a clockwise direction. A strip or a doughnut of polyester felt may be incorporated to the suture line to support the sinus wall. C-The button technique implantation is completed. A B C Figure 19-B Reattachment of the coronary ostia by a combined technique. The classic Kouchoukos aortic button technique is simplified, the dissection of the posterior aspect of the coronary arteries is avoided. A-The ascending aorta is transected 2-3 centimeters distally to the sinotubular junction. The posterior aspect of the coronary arteries is not mobilized. Only at each side of the coronary ostia the aortic root wall is incised (1). Stay suture helps to expose the coronary ostia(2). B-First, the 4-0 Prolene suture is running from inside along the posterior anastomosis in a forehand manner. C-Then,the anastomosis is completed after the anterior aortic root wall is incised (3).The suture is running from outside along the anterior anastomosis in a forehand manner. 297

5 Domingo Liotta, M.D.; Christian Cabrol, M.D; Miguel del Rio, M.D; Armando Diluch, M.D; Adriano Malusardi, M.D. A B C D E Figure 20 Reattachment of coronary ostia by Cabrol s procedure. A- Through the three fibrous trigones and the aortic annuli, 2-0 polyester pledgeted sutures are placed and the 8 or 10 mm collagen impregnated Dacron graft is sutured in position to the left sinus wall closely around the coronary ostium, employing 4-0 Prolene suture. B-The composite valve graft is seated and secured when the annulus sutures are tied down. The interposition coronary tube graft is stretched to be then anastomosed to the right coronary ostial area. One to two extralength centimeters are allowed to prevent overdistention in the anastomosed area due to blood pressure and coronary ostial retraction. C-The distal anastomosis is performed, Figs l0, A-D. Next, the coronary graft is cut longitudinally, 12 mm approximately, to be sutured side-to-side to a similar opening in the composite graft. First, the anastomosis of the inferior margin is done forehand from the inside. D-The coronary graft and the composite graft side-to-side anastomosis is completed. The coronary graft anastomosis is placed at the anterolateral aspect of the composite graft. E- In the original Cabrol operation, with the inclusion technique of Bentall-De Bono, a fistula was created between the enclosed perigraft space and the appendage of the right atrium. The retained aortic wall was then wrapped securely around the composite valve graft, D. A. Cooley, chapter A 10 mm graft for the left coronary ostium and a button technique for the right coronary artery have also been advocated, [32]. 298

6 REPAIR OF THE AORTIC ROOT, THE ASCENDING AORTA AND THE SUBAORTIC OUTFLOW TRACT 25 Figure 21 Symmetrical and asymmetrical aortic root Left drawing: symmetrical sinuses of Valsalva as seen in Marfan s patients. Right drawing: Asymmetrical sinuses of Valsalva as seen in middle-aged patients with medial degenerative atherosclerosis disease. Figure 22 Aortic root asymmetry in a Marfan s patient. Aortogram of a 32 -year- old Marfan s disease patient with asymmetrical aortic root. However, this rare finding in a Marfan s patient, was due to chronic dissection as observed in surgery. Absolute indication for CVG replacement. The replacement of the aortic sinuses, the adjustment of the sinotubular junction, and the replacement of the ascending aorta have already been described in the acute complications section and we will not go over them now. Subaortic outflow tract: adjustment of its fibrous components and remodeled neosinuses A simplified aortic annuloplasty technique may be used in patients with mild annuloaortic ectasia: -The proposed subaortic outflow tract remodeling technique basically employs the 3 trigones: Intervalvular Fibrous Trigone (IVFT); Right anterior Fibrous Trigone (RAFT); Left Anterior Fibrous Trigone (LAFT) and the nadir (belly areas) of the remodeled neosinuses. The three trigones are the strongest components of the subaortic outflow tract. -It avoids passing sutures through the muscular septum (approximately one half of the subaortic outflow tract circumference) (Figs. 4, 23). The muscular septum does not dilate in annuloaortic ectasia. -It avoids the risk of including the conducting system within the sutures. -In fact, the 3 trigones are the cornerstones that will adjust the nadir (belly areas) of the remodeled aortic root sinuses, (Fig. 24, A-C). 299