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Annular Enlargement with Y-Incision and Bioprosthetic Valve Replacement

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posted on 11.07.2022, 19:36 authored by Lamees I. El Nihum, Qasim Al Abri, Moritz C. Wyler von Ballmoos, Michael J. Reardon

The patient is a sixty-seven-year-old female who underwent aortic valve replacement in 2018 with a 19 mm bioprosthetic aortic valve. In this case, the patient presented to the medical center with severe aortic valve regurgitation. 

The case called for the following procedural tasks: a redo sternotomy, an annular enlargement with Y-incision and rectangular patch, and an aortic valve replacement with a 25 mm bioprosthetic valve. 

In the patient’s previous procedure, the aortic valve replacement was performed via a right anterior thoracotomy. Accordingly, this procedure was performed through a redo sternotomy using an oscillating saw. The mediastinal dissection was carried out using electrocautery. 

The cardiopulmonary bypass technique was initiated via central cannulation. Next, a retrograde cardioplegia catheter and a left ventricular vent were installed to maximize myocardial protection. Then a cross-clamp was applied, and the heart was arrested in retrograde fashion. 

An aortotomy was performed, and the aortic valve was exposed and inspected. The bioprosthetic aortic valve explantation was initiated by removing all the annular sutures, and. the valve was easily explanted. The culprit lesion for aortic insufficiency (AI) was identified, as shown in the video. 

Further debridement of the annulus was carried out. In preparation for annular enlargement, the aortic root was dissected extensively to the dome of the left atrium. Annular enlargement began by extending the aortotomy to the commissure between the non-coronary cusp and the left coronary cusp. Next, enlargement returned the incision to the left coronary cusp just before the left main artery, followed by the non-side completely until the membranous septum was reached. The distance of enlargement was measured. Then a Dacron graft was used as a patch. According to the procedure, an appropriately sized patch was determined and fashioned. 

The patch was sutured to the annular enlargement area using 4-0 Prolene sutures. Suturing began in the left coronary cusp side around the corner. Following the action of parachuting the patch downward, the suture line was run to the bottom of the enlargement and all the way to the corner of the aorta and the annulus in the non-coronary cusp side. The suture line was then run all the way up to the edge of the aortotomy on both sides. Careful attention to the stitching of the graft was required to minimize any resulting bleeding. 

Upon completion of the stitching, valve sizing was performed again as illustrated. The 25 mm valve was able to fit there rather easily. The first commissural stitch was placed and then the valve sizer was used to determine the location of the other two commissures following enlargement. Next, a series of pledgeted horizontal mattress stitches were placed around the annulus, starting with the left coronary cusp and followed by the right coronary cusp. Finally, the stitches were placed through the enlargement area, beginning from the outside of the patch and then moving to the inside of the patch. 

All sutures were passed through the bioprosthetic aortic valve. The valve was slid down and tied in place. Careful attention was paid to make sure that the valve was well-seated as it was tied down. The valve was then inspected. The enlarged area is marked clearly with an arrow in the video above. The right and the left coronary arteries were patent, and the patch was sutured to the remaining part of the aortic valve. Then the patch was teared in a tear-shaped fashion to complete the closure of the aortotomy. The stich was started from the other side of the aortotomy to incorporate both sides of the patch into the aortotomy closure, as illustrated in the video. 

After de-airing, the cross-clamp was removed. The patient was weaned from cardiopulmonary bypass, hemostasis was achieved, and routine chest closure was performed. An echocardiography showed a well-seated valve and no perivalvular leak, with a mean gradient of 4 mmHg. The patient was transferred to the ICU, extubated on the same day, and discharged home in the fifth postoperative day.

References

Yang B, Ghita C, Palmer S. Y-incision Aortic Root Enlargement with Modified Aortotomy Upsizing the Annulus by 5 Valve Sizes. Ann Thorac Surg. 2022 Mar 25:S0003-4975(22)00379-4. doi: 10.1016/j.athoracsur.2022.03.013. Epub ahead of print. PMID: 35346629. 

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