Name: standardized technique of aortic valve re-implantation for valve-sparing aortic root replacement
Uploaded: 2017-12-11T15:00:00
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Este trabajo fue financiado por una subvención (N ° 32117) de la Fundación Cardiovascular suizo a RT.

El protocolo sigue los lineamientos institucionales del Comité de ética de investigación.
1. selección previa del paciente
<ol><li>Identificar a pacientes con dilatación de los senos de Valsalva no superior a 60 mm usando la tomografía preoperatoria de la computadora (CT).</li>
	<li>A continuación, seleccione entre estos pacientes un subgrupo con cúspides de la válvula aórtica que aparece normal o casi normal en la ecocardiografía preoperatoria.</li>
	<li>Informar al personal de l...

<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>

En pacientes que presentan aneurisma de la raíz aórtica con cúspides aórticas normales o casi normales, conservación de la válvula de reemplazo aórtico de la raíz es una alternativa más fisiológica y por lo tanto atractiva para reemplazo compuesto del injerto de la aorta y la válvula aórtica con válvula mecánica o tejido. En este protocolo, describimos una técnica simplificada de conservadora de válvula aórtica sustitución de raíz por la implantación de la válvula aórtica. En contraste con la mayor?...

Durante los últimos veinte años, ha evolucionado el tratamiento quirúrgico de aneurisma de la raíz aórtica con cúspides aórticas normales o casi normales gracias a una serie de procedimientos quirúrgicos con el objetivo de preservación de la válvula aórtica nativa1,2, 3,4,5. Conservación de la válvula de reemplazo aórtico de la raíz se logra básicamente por una técnica de remodelación o nueva implantación de la válvula aórtica en un injerto sintético1,3,4,6 que restaura la anatomía fisiológica de la raíz aórtica2. A pesar de las obvias ventajas de la preservación de una válvula aórtica normal durante el reemplazo aórtico de la raíz, muchos cirujanos cardiacos reemplazar la válvula aórtica con cualquiera de los dos sustitutos de válvula mecánica o biológica. Según la base de datos de la sociedad de cirujanos torácicos, sólo el 14% de pacientes que experimentaron el reemplazo aórtico de la raíz en los Estados Unidos entre 2004 y 2010 recibió un procedimiento economizador de válvula7.
En la técnica original de nueva implantación, la válvula aórtica se sutura un injerto sintético prensado horizontal tubular8. Aunque esta técnica estabiliza el anillo aórtico, elimina los senos de Valsalva. Para recrear los senos de Valsalva, esta técnica ha sufrido diversas modificaciones por su inventor, así como otros autores9. Una variación de esta técnica ha sido propuesta por Rama et al., en el que los restos de la pared aórtica apoyando las comisuras se suturan en orificios longitudinales en el tereftalato de polietileno tubular injerto4.
La técnica de remodelación alcanza una reconstrucción más anatómica de la raíz aórtica, pero deja el anillo aórtico sin soporte y expuestos a la futura dilatación. Las varias técnicas quirúrgicas han sido diseñadas para adaptar la base anular aórtica en la remodelación de la raíz aórtica, incluyendo sub-commissural annuloplasty aórtica10, sutura circunferencial annuloplasty11y annuloplasty interno o externo por sintético parcial o completa del anillo12.
A pesar de los excelentes resultados registrados por los autores experimentados, las modificaciones complejidad y periódico de estos procedimientos dificultan su reproducibilidad por otros cirujanos cardíacos y evitar así un número de pacientes adecuados para aprovechar la retención de sus propio de la válvula aórtica. Para mejorar la reproducibilidad de la técnica de re-implantación, hemos utilizado un injerto sintético disponible comercialmente con una porción del seno termofijado en y simplificado la técnica de implantación. El objetivo de este protocolo es describir en detalle esta técnica estandarizada y reproducible, con especial énfasis en la gestión de la primera fila de la línea de sutura proximal y de la colocación de las comisuras en el injerto y la opción del injerto tamaño. Se presentan los primeros resultados y resultados a medio plazo. Selección apropiada de pacientes y las limitaciones de este procedimiento se discuten.

<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

A pesar de las obvias ventajas de la preservación de una válvula aórtica normal durante el reemplazo aórtico de la raíz, la complejidad de los procedimientos de preservación de la válvula impide que un número de cirujanos cardiacos de incorporarlas a su práctica. El objetivo de este protocolo es describir una técnica simplificada y fácil de usar de un procedimiento de reemplazo (VSRR) conservadora de válvula aórtica raíz por la implantación de la válvula aórtica. La selección apropiada de pacientes y las limitaciones de la técnica se discuten.
En 54 pacientes consecutivos, las válvulas aórticas que aparecen normales fueron nuevamente implantadas en una prótesis de poliéster disponible comercialmente con senos en por una técnica simplificada y estandarizada. Colocación de la primera fila de la línea de sutura proximal, la elección del tamaño de prótesis y ajuste de la altura de las comisuras del paciente a la altura de la porción del seno de la prótesis fija fueron ligeramente modificadas de las técnicas de referencia con el objetivo de aumentar su viabilidad para el uso de otros cirujanos cardíacos. La mortalidad temprana y morbilidad así como supervivencia a 5 años, libertad de reoperación de la válvula aórtica y la libertad de regurgitación moderada recurrente se recolectaron en todos los pacientes.
Mortalidad de treinta días, re-esternotomía para la sangría, re-esternotomía para mediastinitis y la incidencia de accidente cerebrovascular fueron muy bajo, 1,8% por cada (1 de 54). Ningún paciente requirió la implantación de marcapasos permanente. En 5 años, supervivencia, libertad de reoperación de la válvula aórtica y la libertad de regurgitación moderada recurrente fueron de 97.5%, 95,2% y 91,6%, respectivamente.
Resultados a medio plazo de la técnica estandarizada de la implantación de la válvula aórtica para conservadora de válvula aórtica de la raíz reemplazo son muy buenas y comparar con técnicas más complejas por cirujanos experimentados. Siguiendo el protocolo actual de la técnica estandarizada de re-implantación, un mayor número de cirujanos cardíacos puede realizar este procedimiento con buenos resultados comparables.

Análisis estadístico:
Las variables continuas se presentan como media ± desviación estándar y las variables categóricas como porcentajes. Se calculan las curvas de Kaplan-Meier para supervivencia, libertad de reoperación de la válvula aórtica y la libertad de regurgitación moderada recurrente usando un paquete de software disponible comercialmente.
Población de pa...

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

Conservación de la válvula de reemplazo aórtico de la raíz tiene la ventaja de preservar la válvula aórtica del paciente. La complejidad de las técnicas divulgadas hasta la fecha restringe su uso a un número limitado de cirujanos cardíacos. Este protocolo describe paso a paso una técnica estandarizada y reproducible por un mayor número de cirujanos cardíacos.

Técnica estandarizada de nueva implantación de válvula aórtica para conservadora de válvula aórtica de la raíz recambio

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.

Research

JoVE Journal

Medicine

Orthotopic Aortic Transplantation in Mice for the Study of Vascular Disease

El trasplante ortotópico aórtica en los ratones para el Estudio de la Enfermedad Vascular

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

Investigación

Medicina

A New Murine Model of Endovascular Aortic Aneurysm Repair

Un modelo murino Nueva endovascular de aneurismas aórticos

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

La constricción aórtica mínimamente invasiva transversal en ratones

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

Reemplazo de la válvula aórtica de raíz completa por los xenoinjertos aórticos sin stent en pacientes con raíces aórticas pequeñas

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

Técnica mínimamente invasiva constricción aórtica transversal en ratones para la inducción de la hipertrofia Ventricular izquierda

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

Técnica y selección de pacientes criterios de minitoracotomía derecha Anterior por acceso mínimo reemplazo de válvula aórtica

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

Mejor registro de 3D CT angiografía con rayos x fluoroscopia para fusión de imágenes durante la implantación de válvula aórtica transcatéter

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

Modelo de trasplante de aórtica cervical murino utilizando una técnica de manguito no sutura modificada

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

Modelo porcino del aneurisma aórtico abdominal infrarrenal

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