Name: standardized technique of aortic valve re-implantation for valve-sparing aortic root replacement
Uploaded: 2017-12-11T15:00:00
Description: Watch this Scientific Journal Video about Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement at JoVE.com

This work was supported by a grant (N&#176; 32117) of the Swiss Cardiovascular Foundation to RT.

The protocol follows the institutional guidelines of the human research ethics committee.
1. Pre-selection of the Patient
<ol>
	<li>Identify patients with dilation of the sinuses of Valsalva not exceeding 60 mm using the pre-operative computer tomography (CT) scan.</li>
	<li>Next, select among these patients a subgroup with normal or near-normal appearing aortic valve cusps on their pre-operative echocardiography.</li>
	<li>Inform the staff of the possibility of a valve sparing aortic root r...

<ol>
	<li>David, T. E., Feindel, C. M., Bos, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Repair+of+the+aortic+valve+in+patients+with+aortic+insufficiency+and+aortic+root+aneurysm.">Repair of the aortic valve in patients with aortic insufficiency and aortic root aneurysm.</a> J Thorac Cardiovasc Surg. 109 (2), 345-352 (1995).</li><li>Yacoub, M. H., Gehle, P., Chandrasekaran, V., Birks, E. J., Child, A., Radley-Smith, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Late+results+of+a+valve-preserving+operation+in+patients+with+aneurysms+of+the+ascending+aorta+and+root.">Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root.</a> J Thorac Cardiovasc Surg. 115 (5), 1080-1090 (1998).</li><li>De Paulis, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=One-year+appraisal+of+a+new+aortic+root+conduit+with+sinuses+of+Valsalva.">One-year appraisal of a new aortic root conduit with sinuses of Valsalva.</a> J Thorac Cardiovasc Surg. 123 (1), 33-39 (2002).</li><li>Rama, A., Rubin, S., Bonnet, N., Gandjbakhch, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+technique+of+aortic+root+reconstruction+with+aortic+valve+annuloplasty+in+ascending+aortic+aneurysm.">New technique of aortic root reconstruction with aortic valve annuloplasty in ascending aortic aneurysm.</a> Ann Thorac Surg. 83 (5), 1908-1910 (2007).</li><li>Richardt, D., Karluss, A., Schmidtke, C., Sievers, H. H., Scharfschwerdt, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+sinus+prosthesis+for+aortic+valve-sparing+maintaining+the+shape+of+the+root+at+systemic+pressure.">A new sinus prosthesis for aortic valve-sparing maintaining the shape of the root at systemic pressure.</a> Ann Thorac Surg. 89 (3), 943-946 (2010).</li><li>Schmidtke, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=First+clinical+results+with+the+new+sinus+prosthesis+used+for+valve-sparing+aortic+root+replacement.">First clinical results with the new sinus prosthesis used for valve-sparing aortic root replacement.</a> Eur J Cardiothorac Surg. 43 (3), 585-590 (2013).</li><li>Stamou, S. C., Williams, M. L., Gunn, T. M., Hagberg, R. C., Lobdell, K. W., Kouchoukos, N. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+root+surgery+in+the+United+States:+a+report+from+the+Society+of+Thoracic+Surgeons+database.">Aortic root surgery in the United States: a report from the Society of Thoracic Surgeons database.</a> J Thorac Cardiovasc Surg. 149 (1), 116-122 (2015).</li><li>David, T. E., Feindel, C. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+aortic+valve-sparing+operation+for+patients+with+aortic+incompetence+and+aneurysm+of+the+ascending+aorta.">An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.</a> J Thorac Cardiovasc Surg. 103 (4), 617-621 (1992).</li><li>Hopkins, R. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+valve+leaflet+sparing+and+salvage+surgery:+evolution+of+techniques+for+aortic+root+reconstruction.">Aortic valve leaflet sparing and salvage surgery: evolution of techniques for aortic root reconstruction.</a> Eur J Cardiothorac Surg. 24 (6), 886-897 (2003).</li><li>Mve Mvondo, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+aortic+valve+regurgitation+secondary+to+ascending+aorta+aneurysm:+is+adjunctive+subcommissural+annuloplasty+necessary?.">Surgical treatment of aortic valve regurgitation secondary to ascending aorta aneurysm: is adjunctive subcommissural annuloplasty necessary?.</a> Ann Thorac Surg. 95 (2), 586-592 (2013).</li><li>Aicher, D., Schneider, U., Schmied, W., Kunihara, T., Tochii, M., Sch&#228;fers, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Early+results+with+annular+support+in+reconstruction+of+the+bicuspid+aortic+valve.">Early results with annular support in reconstruction of the bicuspid aortic valve.</a> J Thorac Cardiovasc Surg. 145 (3 Suppl), S30-S34 (2013).</li><li>Lansac, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+prosthetic+ring+annuloplasty:+a+useful+adjunct+to+a+standardized+aortic+valve-sparing+procedure?.">Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valve-sparing procedure?.</a> Eur J Cardiothorac Surg. 29 (4), 537-544 (2006).</li><li>Tavakoli, R., Jamshidi, P., Gassmann, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Full-root+aortic+valve+replacement+by+stentless+aortic+xenografts+in+patients+with+small+aortic+root.">Full-root aortic valve replacement by stentless aortic xenografts in patients with small aortic root.</a> J Vis Exp. (123), e55632 (2017).</li><li>Zoghbi, W. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Recommendations+for+evaluation+of+the+severity+of+native+valvular+regurgitation+with+two-dimensional+and+Doppler+echocardiography.">Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography.</a> J Am Soc Echocardiogr. 16 (7), 777-802 (2003).</li><li>Cohle, S. D., Delavan, J. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Coronary+artery+compression+by+teflon+pledget+granuloma+following+aortic+valve+replacement.">Coronary artery compression by teflon pledget granuloma following aortic valve replacement.</a> J Forensic Sci. 42 (5), 945-946 (1997).</li><li>Vallabhajosyula, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Geometric+orientation+of+the+aortic+neoroot+in+patients+with+raphed+bicuspid+aortic+valve+disease+undergoing+primary+cusp+repair+and+a+root+reimplantation+procedure.">Geometric orientation of the aortic neoroot in patients with raphed bicuspid aortic valve disease undergoing primary cusp repair and a root reimplantation procedure.</a> Eur J Cardiothorac Surg. 45 (1), 174-180 (2014).</li><li>David, T. E., David, C. M., Feindel, C. M., Manlhiot, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reimplantation+of+the+aortic+valve+at+20+years.">Reimplantation of the aortic valve at 20 years.</a> J Thorac Cardiovasc Surg. 153 (2), 232-238 (2017).</li><li>Zehr, K. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Form+ever+follows+function.">Form ever follows function.</a> J Thorac Cardiovasc Surg. 151 (1), 120-121 (2016).</li><li>De Paulis, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+results+of+the+valve+reimplantation+technique+using+a+graft+with+sinuses.">Long-term results of the valve reimplantation technique using a graft with sinuses.</a> J Thorac Cardiovasc Surg. 151 (1), 112-119 (2016).</li><li>Gleason, T. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+graft+formulation+and+modification+of+the+David+reimplantation+technique.">New graft formulation and modification of the David reimplantation technique.</a> J Thorac Cardiovasc Surg. 130 (2), 601-603 (2005).</li><li>Demers, P., Miller, D. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simple+modification+of+"T.+David-V"+valve-sparing+aortic+root+replacement+to+create+graft+pseudosinuses.">Simple modification of "T. David-V" valve-sparing aortic root replacement to create graft pseudosinuses.</a> Ann Thorac Surg. 78 (4), 1479-1481 (2004).</li><li>David, T. E., Maganti, M., Armstrog, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+root+aneurysm:+principles+of+repair+and+long-term+follow-up.">Aortic root aneurysm: principles of repair and long-term follow-up.</a> J Thorac Cardiovasc Surg. 140 (6S), S14-S19 (2010).</li><li>Shrestha, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+results+after+aortic+valve-sparing+operation+(David+I).">Long-term results after aortic valve-sparing operation (David I).</a> Eur J Cardiothorac Surg. 41 (1), 56-61 (2012).</li></ol>

In patients presenting with aortic root aneurysm with normal or near-normal aortic cusps, valve-sparing aortic root replacement is a more physiological and hence attractive alternative to composite graft replacement of the aorta and the aortic valve with mechanical or tissue valve. In this protocol, we describe a simplified technique of valve-sparing aortic root replacement by re-implantation of the aortic valve. In contrast to the majority of the previously reported techniques3,<sup cl...

During the past twenty years, the surgical treatment of aortic root aneurysm with normal or near-normal aortic cusps has evolved thanks to a series of surgical procedures aiming at preservation of the native aortic valve1,2,3,4,5. Valve-sparing aortic root replacement is basically accomplished either by re-implantation of the aortic valve inside a synthetic graft1,3,4,6 or by a remodeling technique which restores the physiological anatomy of the aortic root2. Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, many cardiac surgeons replace the aortic valve with either mechanical or biological valve substitutes. According to the Society of Thoracic Surgeons database, only 14% of patients who underwent aortic root replacement in the United States between 2004 and 2010 received a valve-sparing procedure7.
In the original re-implantation technique, the aortic valve is sutured inside a tubular horizontally crimped synthetic graft8. Although this technique stabilizes the aortic annulus, it eliminates the sinuses of Valsalva. In order to recreate the sinuses of Valsalva, this technique has undergone several modifications by its inventor as well as other authors9. A variation of this technique has been proposed by Rama et al., in which the remnants of the aortic wall supporting the commissures are sutured into longitudinal openings made in the tubular polyethylene terephthalate graft4.
The remodeling technique achieves a more anatomical reconstruction of the aortic root but leaves the aortic annulus unsupported and exposed to future dilatation. Various surgical techniques have been designed to tailor the aortic annular base in aortic root remodeling, including sub-commissural aortic annuloplasty10, circumferential suture annuloplasty11, and internal or external annuloplasty by synthetic partial or complete ring12.
Despite the excellent results reported by experienced authors, the complexity and periodical modifications of these procedures hamper their reproducibility by other cardiac surgeons and thus prevent a number of suitable patients to benefit from retaining their own aortic valve. In order to enhance the reproducibility of the re-implantation technique, we have used a commercially available synthetic graft with an uncrimped, pre-shaped sinus portion and simplified the implantation technique. The aim of this protocol is to describe in detail this standardized and reproducible technique with particular emphasis on the management of the first row of the proximal suture line and of the placement of the commissures inside the graft and the choice of the graft size. Early outcomes and mid-term results are presented. Proper selection of patients for and limitations of this procedure are discussed.

<table>
	<tbody>
		<tr>
			<td>Heart surgery infrastructure:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Heart Lung Machine</td>
			<td>Stockert</td>
			<td>SIII</td>
			<td></td>
		</tr>
		<tr>
			<td>EOPA 24Fr. arterial cannula</td>
			<td>Medtronic</td>
			<td>77624</td>
			<td></td>
		</tr>
		<tr>
			<td>Atrial caval venous cannula 34/48Fr.</td>
			<td>Medtronic</td>
			<td>93448</td>
			<td></td>
		</tr>
		<tr>
			<td>LV vent catheter 17Fr.</td>
			<td>Edwards</td>
			<td>E061</td>
			<td></td>
		</tr>
		<tr>
			<td>Antegrade 9Fr. cardioplegia cannula</td>
			<td>Edwards</td>
			<td>AR012V</td>
			<td></td>
		</tr>
		<tr>
			<td>Retrograde 14Fr. cardioplegia cannula&#160;</td>
			<td>Edwards</td>
			<td>NPC014&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Coronary artery ostial cannula 90&#176;</td>
			<td>Medtronic</td>
			<td>30155</td>
			<td></td>
		</tr>
		<tr>
			<td>Coronary artery ostial cannula 45&#176;</td>
			<td>Medtronic</td>
			<td>30255</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Pre-shaped sinus graft</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cardioroot 28 mm</td>
			<td>Maquet</td>
			<td>HEWROOT0028</td>
			<td></td>
		</tr>
		<tr>
			<td>Cardioroot 30 mm</td>
			<td>Maquet</td>
			<td>HEWROOT0030</td>
			<td></td>
		</tr>
		<tr>
			<td>Cardioroot 32 mm</td>
			<td>Maquet</td>
			<td>HEWROOT0032</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Electrocautery</td>
			<td>Covidien</td>
			<td>Force FX</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Sutures:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Polypropylene 4/0</td>
			<td>Ethicon</td>
			<td>8871H</td>
			<td></td>
		</tr>
		<tr>
			<td>Polypropylene 5/0</td>
			<td>Ethicon</td>
			<td>8870H</td>
			<td></td>
		</tr>
		<tr>
			<td>Polypropylene 6/0</td>
			<td>Ethicon</td>
			<td>EH7400H</td>
			<td></td>
		</tr>
		<tr>
			<td>Braided polyesther 2/0 ligature with polybutylate coating&#160;</td>
			<td>Ethicon</td>
			<td>X305H</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Micro knife Sharpoint&#160;</td>
			<td>TYCO Healthcare PTY&#160;</td>
			<td>78-6900</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Drugs:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Midazolam</td>
			<td>Roche Pharma</td>
			<td>N05CD08</td>
			<td></td>
		</tr>
		<tr>
			<td>Rocuronium</td>
			<td>MSD Merck Sharp &#38; Dohme&#160;</td>
			<td>M03AC09</td>
			<td></td>
		</tr>
		<tr>
			<td>Propofol</td>
			<td>Fresenius Kabi</td>
			<td>N01AX10</td>
			<td></td>
		</tr>
		<tr>
			<td>Fentanil</td>
			<td>Actavis</td>
			<td>N01AH01</td>
			<td></td>
		</tr>
		<tr>
			<td>Heparin</td>
			<td>Braun</td>
			<td>B01AB01</td>
			<td></td>
		</tr>
		<tr>
			<td>Protamin</td>
			<td>MEDA Pharmaceutical</td>
			<td>V03AB14</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Instruments:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cooley vascular aortic clamp</td>
			<td>Delacroix-Chevalier</td>
			<td>DC40810-16</td>
			<td></td>
		</tr>
		<tr>
			<td>Dissection forceps Carpentier</td>
			<td>Delacroix-Chevalier</td>
			<td>DC13110-28&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Scissors Metzenbaum</td>
			<td>Delacroix-Chevalier</td>
			<td>B351751</td>
			<td></td>
		</tr>
		<tr>
			<td>Needle holder Ryder</td>
			<td>Delacroix-Chevalier</td>
			<td>DC51130-20&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Dissection forceps DeBakey</td>
			<td>Delacroix-Chevalier</td>
			<td>DC12000-21&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Micro needle holder Jacobson</td>
			<td>Delacroix-Chevalier</td>
			<td>DC50002-21&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Micro scisors Jacobson</td>
			<td>Delacroix-Chevalier</td>
			<td>DC20057-21&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Lung retractor</td>
			<td>Delacroix-Chevalier</td>
			<td>B803990</td>
			<td></td>
		</tr>
		<tr>
			<td>Allis clamp</td>
			<td>Delacroix-Chevalier</td>
			<td>DC45907-25&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>O&#8217;Shaugnessy Dissector</td>
			<td>Delacroix-Chevalier</td>
			<td>B60650</td>
			<td></td>
		</tr>
		<tr>
			<td>18 blade knife</td>
			<td>Delacroix-Chevalier</td>
			<td>B130180</td>
			<td></td>
		</tr>
		<tr>
			<td>Leriche haemostatic clamp</td>
			<td>Delacroix-Chevalier</td>
			<td>B86555</td>
			<td></td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog Number</td>
			<td>Comments</td>
		</tr>
		<tr>
			<td>Data analysis</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Kaplan Meier curves</td>
			<td>GraphPad</td>
			<td>Prism 7</td>
			<td></td>
		</tr>
	</tbody>
</table>

standardized technique of aortic valve re-implantation for valve-sparing aortic root replacement

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed.
In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients.
Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively.
Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Statistical Analysis:
Continuous variables are presented as mean &#177; standard deviation and categorical variables as percentages. Kaplan-Meier curves are calculated for survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation using a commercially available software package.
Patient Population:
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Watch this Scientific Journal Video about Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement at JoVE.com

Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Valve-sparing aortic root replacement has the advantage of preserving the patient&#39;s own aortic valve. The complexity of the reported techniques to date restricts their use to a limited number of cardiac surgeons. This protocol describes step-by-step a standardized technique reproducible by a greater number of cardiac surgeons.

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures ...

The overall goal of this protocol is to describe in detail a Standardized and Reproducible Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement with particular emphasis on the management of the first row of the proximal suture. This method can help answer key questions regarding aortic valve preservation during aortic route replacement. The main advantage of this technique is that it uses a single graft with a pre-shaped sinus portion that helps standardization of the procedure.Begin this procedure with patient selection as detailed in the text protocol. Prepare the surgery suite and the patient for surgery as previously described. Access the heart through a median sternotomy as referenced in the text protocol.Then, prepare the aortic route for replacement by first grabbing the ascending aorta at the sinotubular junction with Carpentier dissection forceps. Then, make a horizontal opening with the 11 blade knife. Complete the aortotomy circumferentially and horizontally with Metzenbaum scissors.After having transected the aorta, verify the absence of calcifications of the cusps and/or thickening and retraction of their free margin. Check the coronary ostia. Dissect the outer aspect of the noncoronary sinus down to the roof of the left atrium, free from the surrounding tissue.Next, detach the right coronary ostium from the aortic wall with a generous circular patch, leaving five millimeters of the aortic wall remnant attached to the insertion of the cusps. Free the commissure between the noncoronary and right coronary sinus from the surrounding tissue. Dissect the outer aspect of the aortic wall remnant of the right coronary sinus free from the outflow tract of the right ventricle.Then, free the outer aspect of the commissure between the noncoronary and left coronary sinus down to the roof of the left atrium. Excise the aortic wall of the noncoronary sinus leaving five millimeters of the aortic wall remnant attached to the insertion of the cusp. Separate the outer aspect of the commissure between the right and left coronary sinus from the surrounding tissue.Take care not to injure the pulmonary artery. Then, detach the left coronary ostium from the aortic wall with the generous circular patch, leaving five millimeters of the aortic wall remnant attached to the insertion of the cusp. Mobilize the left main coronary artery over its first 10 millimeters.Dissect the outer aspect of the aortic wall remnant of the left coronary sinus free from the roof of the left atrium. Start the proximal implantation of the prosthesis as described in the text protocol. The single most difficult step of this procedure is the placement of the first row of the sutures by taking care not to injure the membranous septum and the anterior leaflet of the mitral valve.Place the fourth suture next to the third one in the direction of the commissure between the noncoronary and right coronary sinus. Avoid the base of the commissural triangle between the noncoronary and right coronary sinus, so as to not compromise the membranous septum. Start the first suture of the right coronary sinus two millimeters away from the base of the commissural triangle of the commissure between the noncoronary and right coronary sinus, thus skipping the membranous septum.Put the following sutures of the right coronary sinus in the direction of the commissure between the left and right coronary sinus. Place the fourth suture of the right coronary sinus at the base of the commissural triangle of the commissure between the left and right coronary sinus. Now pass the mattress sutures inside out into the prosthesis.Slide down the prosthesis, thus placing the valve inside it. Tie the mattress sutures gently and cut them. Start the second row of the proximal anastomosis as described in the text protocol.Finish the second row of the proximal anastomosis by fixing the remnant of the aortic wall in parallel to the insertion of the cusp up to the commissure, between the noncoronary and right coronary sinus. Tie the two suture ends together at each commissure. Check the absence of aortic regurgitation by filling the prosthesis with saline and applying suction to the vent placed to the right pulmonary vein and the mitral valve into the left ventricle.Reconnect the coronary ostia to the prosthesis by first creating a button hole in the left sinus of the prosthesis and placing the first stitch as detailed in the text protocol. Place the second stitch two millimeters to the right of the first one from inside out of the prosthesis and outside in of the left coronary ostium up to the mid height of the right ridge of the anastomosis. Put the suture end under light tension.Continue the running suture on the left ridge of the anastomosis from outside in the prosthesis and from inside out of the left coronary ostium to meet the other end. Tie the two ends together. After creating a button hole on the right sinus of the prosthesis and starting a suture as detailed in the text protocol, continue the suture to the mid height of the right ridge of the anastomosis and put the end under light tension.Complete the anastomosis by running the left ridge of the anastomosis to meet the other end. Tie the two ends together. Start the distal anastomosis as described in the text.Complete the distal anastomosis by running the suture on the left ridge to meet the other end. Tie the ends together. Tilt the operating table in the Trendelenburg position.Let the pump flow reduce to 50%of the full flow and slowly remove the aortic cross clamp under gentle aspiration of the left ventricular vent. After the procedure, resume the full flow of the cardiopulmonary bypass and check the operative field for undue surgical bleeding. Rewarm and separate the patient from the cardiopulmonary bypass.Finally, perform a post-operative patient care as referenced in the text protocol. The Kaplan Meier survival curve reveals that there were a total of three deaths in this series during the follow-up period. Thus, the five-year survival rate in this series was 97.5%and the 10-year survival rate was 92.5%Two of the four patients with recurrent moderate aortic regurgitation, underwent re-operation because of the progredient left ventricle dilatation.As a result, the freedom of re-operation for aortic valve replacement was 95.2%at five years and 93%at 10 years. For patients developed moderate aortic regurgitation during the follow up period. Therefore, their freedom from moderate aortic regurgitation was 91.6%at five years and 90%at 10 years.Once mastered, this technique can be done in 150 minutes if it is performed properly. While attempting this procedure, it is important to remember to entirely free the aortic route from the surrounding tissue. After watching this video, you should have a good understanding of how to avoid injury to the membranous septum during the procedure.Following this protocol, other surgical procedures on the aortic route can be performed to address different route pathologies. After its development, this technique opened the era of the preservation of the normal aortic valve during aortic route surgery. Don't forget that operating on the aortic route can be hazardous and gentle dissection of the tissue and placement of the sutures should always be taken while performing this procedure.

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Research

JoVE Journal

Medicine

Orthotopic Aortic Transplantation in Mice for the Study of Vascular Disease

Vascular procedures involving anastomoses in the mouse are generally thought to be difficult and highly dependent on the skill of the individual surgeon. This is largely true, but there are a number of important principles that can reduce the difficulty of these procedures and enhance reproducibility. Orthotopic aortic transplantation is an excellent procedure in which to learn these principles because it involves only two end-to-end anastomoses, but requires good suturing technique and handling of the vessels for consistent success. This procedure begins with the procurement of a length of abdominal aorta from a donor animal, followed by division of the native aorta in the recipient. The procured aorta is then placed between the divided ends of the recipient aorta and sutured into place using end-to-end anastomoses. To accomplish this objective successfully requires a high degree of concentration, good tools, a steady hand, and an appreciation of how easily the vasculature of a mouse can be damaged, resulting in thrombosis. Learning these important principles is what occupies most of the beginner's time when learning microsurgery in small rodents. Throughout this protocol, we refer to these important points. This model can be used to study vascular disease in a variety of different experimental systems1-8. In the context shown here, it is most often used for the study of post-transplant vascular disease, a common long-term complication of solid organ transplantation in which intimal hyperplasia occurs within the allograft. The primary advantage of the model is that it facilitates quantitative morphometric analyses and the transplanted vessel lies contiguous to the endogenous vessel, which can serve as an additional control9. The technique shown here is most often used for mice weighing 18-25 grams. We have accumulated most of our experience using the C57BL/6J, BALB/cJ, and C3H/HeJ strains.

We describe a technique in which a section of the abdominal aorta from a mouse is transplanted orthotopically to just below the renal arteries in an allogeneic or syngeneic recipient. This technique can be useful in studies in which transplantation of large arteries of uniform size is deemed advantageous.

Vascular procedures involving anastomoses in the mouse are generally thought to be difficult and highly dependent on the skill of the individual surgeon. ...

A New Murine Model of Endovascular Aortic Aneurysm Repair

Endovascular aneurysm exclusion is a validated technique to prevent aneurysm rupture. Long-term results highlight technique limitations and new aspects of Abdominal aortic aneurysm (AAA) pathophysiology. There is no abdominal aortic aneurysm endograft exclusion model cheap and reproducible, which would allow deep investigations of AAA before and after treatment. We hereby describe how to induce, and then to exclude with a covered coronary stentgraft an abdominal aortic aneurysm in a rat. The well known elastase induced AAA model was first reported in 19901 in a rat, then described in mice2. Elastin degradation leads to dilation of the aorta with inflammatory infiltration of the abdominal wall and intra luminal thrombus, matching with human AAA. Endovascular exclusion with small covered stentgraft is then performed, excluding any interactions between circulating blood and the aneurysm thrombus. Appropriate exclusion and stentgraft patency is confirmed before euthanasia by an angiography thought the left carotid artery. Partial control of elastase diffusion makes aneurysm shape different for each animal. It is difficult to create an aneurysm, which will allow an appropriate length of aorta below the aneurysm for an easy stentgraft introduction, and with adequate proximal and distal neck to prevent endoleaks. Lots of failure can result to stentgraft introduction which sometimes lead to aorta tear with pain and troubles to stitch it, and endothelial damage with post op aorta thrombosis. Giving aspirin to rats before stentgraft implantation decreases failure rate without major hemorrhage. Clamping time activates neutrophils, endothelium and platelets, and may interfere with biological analysis.

Histological and biochemical modifications after aneurysm endograft exclusion are still unclear. We describe a new model of endograft implantation on a murine aneurysm. Through thrombus analysis with and without persistant circulating blood stream interface, and new endovascular biomaterials evaluation, this model will help to better understand endovascular aneurysm exclusion pathobiology.

Endovascular aneurysm exclusion is a validated technique to prevent aneurysm rupture. Long-term results highlight technique limitations and new aspects of ...

Minimally Invasive Transverse Aortic Constriction in Mice

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard open-chest transverse aortic constriction (TAC). Although transverse aortic constriction is a highly functional method for the induction of high pressure in the left ventricle, it is a more difficult and lengthy procedure due to its use of artificial ventilation with tracheal intubation. TAC is oftentimes also less survivable, as the newer method, MTAC, neither requires the cutting of the ribs and intercostal muscles nor tracheal intubation with a ventilation setup. In MTAC, as opposed to a thoracotomy to access to the chest cavity, the aortic arch is reached through a midline incision in the anterior neck. The thyroid is pulled back to reveal the sternal notch. The sternum is subsequently cut down to the second rib level, and the aortic arch is reached simply by separating the connective tissues and thymus. From there, a suture can be wrapped around the arch and tied with a spacer, and then the sternal cut and skin can be closed. MTAC is a much faster and less invasive way to induce left ventricular hypertension and enables the possibility for high-throughput studies. The success of the constriction can be verified using high-frequency trans-thoracic echocardiography, particularly color Doppler and pulsed-wave Doppler, to determine the flow velocities of the aortic arch and left and right carotid arteries, the dimension of the blood vessels, and the left ventricular function and morphology. A successful constriction will also trigger significant histopathological changes, such as cardiac muscle cell hypertrophy with interstitial and perivascular fibrosis. Here, the procedure of MTAC is described, demonstrating how the resulting flow changes in the carotid arteries can be examined with echocardiography, gross morphology, and histopathological changes in the heart.

Minimally invasive transverse aortic constriction (MTAC) conserves the essentials of regular transverse aortic constriction (TAC) while eliminating the use of a ventilator with tracheal intubation. It proves to be a highly desirable method for high-throughput studies on left ventricular overload, particularly in translational studies.

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard ...

Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial valve might not meet the functional needs. The implantation of a too-small stented pericardial valve, leading to an effective orifice area indexed to a body surface area less than 0.85 cm2/m2, is regarded as prosthesis-patient mismatch (PPM). A PPM negatively affects the regression of left ventricular hypertrophy and thus the normalization of left ventricular function and the alleviation of symptoms. Persistent left ventricular hypertrophy is associated with an increased risk of arrhythmias and sudden cardiac death. In the case of predictable PPM, there are three options: 1) accept the PPM resulting from the implantation of a stented pericardial valve when comorbidities of the patient forbid the more technically demanding operative technique of implanting a larger prosthesis, 2) enlarge the aortic root to accommodate a larger stented valve substitute, or 3) implant a stentless biological valve or a homograft. Compared to classical aortic valve replacement with stented pericardial valves, the full-root implantation of stentless aortic xenografts offers the possibility of implanting a 3-4 mm larger valve in a given patient, thus allowing significant reduction in transvalvular gradients. However, a number of cardiac surgeons are reluctant to transform a classical aortic valve replacement with stented pericardial valves into the more technically challenging full-root implantation of stentless aortic xenografts. Given the potential hemodynamic advantages of stentless aortic xenografts, we have adopted full-root implantation to avoid PPM in patients with small aortic roots necessitating an aortic valve replacement. Here, we describe in detail a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses. Limitations of this technique and alternative options are discussed.

Full-root aortic valve replacement by stentless aortic xenograft is a viable option in patients with small aortic roots. We describe, a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses, and discuss its limitations and alternative options.

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial ...

Technique of Minimally Invasive Transverse Aortic Constriction in Mice for Induction of Left Ventricular Hypertrophy

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure overload-induced left ventricular hypertrophy (LVH) and its progression to heart failure. In the majority of the reported investigations, this procedure is performed with intubation and ventilation of the animal which renders it demanding and time-consuming and adds to the surgical burden to the animal. The aim of this protocol is to describe a simplified technique of minimally invasive TAC without intubation and ventilation of mice. Critical steps of the technique are emphasized in order to achieve low mortality and high efficiency in inducing LVH.
Male C57BL/6 mice (10-week-old, 25-30 g, n=60) were anesthetized with a single intraperitoneal injection of a mixture of ketamine and xylazine. In a spontaneously breathing animal following a 3-4 mm upper partial sternotomy, a segment of 6/0 silk suture threaded through the eye of a ligation aid was passed under the aortic arch and tied over a blunted 27-gauge needle. Sham-operated animals underwent the same surgical preparation but without aortic constriction. The efficacy of the procedure in inducing LVH is attested by a significant increase in the heart/body weight ratio. This ratio is obtained at days 3, 7, 14 and 28 after surgery (n = 6 - 10 in each group and each time point). Using our technique, LVH is observed in TAC compared to sham animals from day 7 through day 28. Operative and late (over 28 days) mortalities are both very low at 1.7%.
In conclusion, our cost-effective technique of minimally invasive TAC in mice carries very low operative and post-operative mortalities and is highly efficient in inducing LVH. It simplifies the operative procedure and reduces the strain put on the animal. It can be easily performed by following the critical steps described in this protocol.

The aim of this protocol is to describe step-by-step the technique of minimally invasive transverse aortic constriction (TAC) in mice. By elimination of intubation and ventilation which are mandatory for the commonly used standard procedure, minimally invasive TAC simplifies the operative procedure and reduces the strain put on the animal.

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure ...

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

The goal of this protocol is to describe in detail the technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy and central aortic cannulation. This technique can potentially enhance patients&#39; comfort and, by reducing post-operative morbidity, promote lowering the length of stay and global costs.

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The ...

Improved Registration of 3D CT Angiography with X-ray Fluoroscopy for Image Fusion During Transcatheter Aortic Valve Implantation

The fusion of 3D anatomical models derived from high-fidelity pre-interventional computed tomography angiography (CTA), and x-ray (XR) fluoroscopy to facilitate anatomical guidance is of huge interest for complex cardiac interventions like TAVI procedures with cerebral protection. Co-registration of CTA and XR has been introduced either based on additional intraoperative non-/contrast-enhanced cone-beam computed tomography (CBCT) or two separate aortograms. With the related increase of radiation exposure and/or contrast agent (CA) dose, a potential additional risk for the patient is introduced. Here, we propose a modified co-registration approach making use of arteriograms of the iliofemoral arteries, routinely performed during the femoral puncture and sheath introduction. On-the-fly refinement of the co-registration during the on-going procedure enables accurate co-registration without any additional angiograms, thus reducing CA, XR dose and procedure time, while simultaneously improving operator confidence and procedure safety.

The aim of this study was to improve the co-registration for image fusion (IF) of pre-interventional CT data with real-time x-ray (XR) fluoroscopy during transfemoral transcatheter aortic valve implantation (TAVI).

The fusion of 3D anatomical models derived from high-fidelity pre-interventional computed tomography angiography (CTA), and x-ray (XR) fluoroscopy to ...

Murine Cervical Aortic Transplantation Model using a Modified Non-Suture Cuff Technique

With the introduction of powerful immunosuppressive protocols, distinct advances are possible in the prevention and therapy of acute rejection episodes. However, only minor improvement in the long-term results of transplanted solid organs could be observed over the past decades. In this context, chronic allograft vasculopathy (CAV) still represents the leading cause of late organ failure in cardiac, renal and pulmonary transplantation.
Thus far, the underlying pathogenesis of CAV development remains unclear, explaining why effective treatment strategies are presently missing and emphasizing a need for relevant experimental models in order to study the underlying pathophysiology leading to CAV formation. The following protocol describes a murine heterotopic cervical aortic transplantation model using a modified non-suture cuff technique. In this technique, a segment of the thoracic aorta is interpositioned in the right common carotid artery. With the use of the non-suture cuff technique, an easy to learn and reproducible model can be established, minimizing the possible heterogeneity of sutured vascular micro anastomoses.

Here, we present a protocol of heterotopic aortic transplantation in mice using the non-suture cuff technique in a cervical murine model. This model can be used to study the underlying pathology of chronic allograft vasculopathy (CAV) and can help evaluate new therapeutic agents in order to prevent its formation.

With the introduction of powerful immunosuppressive protocols, distinct advances are possible in the prevention and therapy of acute rejection episodes. ...

Porcine Model of Infrarenal Abdominal Aortic Aneurysm

Large animal models to study abdominal aortic aneurysms are sparse. The purpose of this model is to create reproducible, clinically significant infrarenal abdominal aortic aneurysms (AAA) in swine. To achieve this, we use a combination of balloon angioplasty, elastase and collagenase, and a lysyl oxidase inhibitor, called &#946;-aminopropionitrile (BAPN), to create clinically significant infrarenal aortic aneurysms, analogous to human disease.
Noncastrated male swine are fed BAPN for 7 days prior to surgery to achieve a steady state in the blood. A midline laparotomy is performed and the infrarenal aorta is circumferentially dissected. An initial measurement is recorded prior to aneurysm induction with a combination of balloon angioplasty, elastase (500 units)/collagenase (8000 units) perfusion, and topical elastase application. Swine are fed BAPN daily until terminal procedure on either postoperative day 7, 14, or 28, at which time the aneurysm is measured, and tissue procured. BAPN + surgery pigs are compared to pigs that underwent surgery alone.
Swine treated with BAPN and surgery had a mean aortic dilation of 89.9% &#177; 47.4% at day 7, 105.4% &#177; 58.1% at day 14, and 113.5% &#177; 30.2% at day 28. Pigs treated with surgery alone had significantly smaller aneurysms compared to BAPN + surgery animals at day 28 (p &#60; 0.0003). The BAPN + surgery group had macroscopic and immunohistochemical evidence of end stage aneurysmal disease.
Clinically significant infrarenal AAA can be induced using balloon angioplasty, elastase/collagenase perfusion and topical application, supplemented with oral BAPN. This model creates large, clinically significant AAA with hallmarks of human disease. This has important implications for the elucidation of AAA pathogenesis and testing of novel therapies and devices for the treatment of AAA. Limitations of the model include variation in BAPN ingested by swine, quality of elastase perfusion, and cost of BAPN.&#160;

This novel model creates robust infrarenal abdominal aortic aneurysms in swine using a combination of balloon angioplasty, elastase/collagenase perfusion, topical elastase application, and oral compound &#946;-aminopropionitrile administration, which interferes with collagen cross-linking.

Large animal models to study abdominal aortic aneurysms are sparse. The purpose of this model is to create reproducible, clinically significant infrarenal ...

The Intra-Aortic Balloon Pump

Cardiogenic shock remains one of the most challenging clinical syndromes in modern medicine. Mechanical support is being increasingly used in the management of cardiogenic shock. Intra-aortic balloon pump (IABP) is one of the earliest and most widely used types of mechanical circulatory support. The device acts by external counterpulsation and uses systolic unloading and diastolic augmentation of aortic pressure to improve hemodynamics. Although IABP provides less hemodynamic support when compared with newer mechanical circulatory support devices, it can still be the mechanical support device of choice in appropriate situations because of its relative simplicity of insertion and removal, need for smaller size vascular access and better safety profile. In this review, we discuss the equipment, procedural and technical aspects, hemodynamic effects, indications, evidence, current status and recent advances in the use of IABP in cardiogenic shock.

We describe the steps for the percutaneous implantation of the intra-aortic balloon pump (IABP), a mechanical circulatory support device. It acts by counterpulsation, inflating at the onset of diastole, augmenting diastolic aortic pressure and improving coronary blood flow and systemic perfusion, and deflating before systole, reducing left ventricular afterload.