BAV Repair and Aortic Root Replacement: Reimplantation
This video demonstrates valve-sparing root replacement with a re-implantation technique in a 52-year-old female with a dilated root aneurysm and a bicuspid aortic valve with mild aortic valve regurgitation. The procedure was done via median sternotomy. Routine cannulation for cardiopulmonary bypass was performed. A left ventricular vent was inserted through the right superior pulmonary vein and cross clamping was performed, and the heart was arrested in an antegrade fashion. The aorta was opened about the sinotubular junction. The root dissection was started. The right coronary button was isolated and suspended, followed by the left coronary button. The remaining part of the aorta was also transected. Suspension stitches were placed for an initial valve assessment. Dissection of the root was started. The area between the aortic root and the right ventricular outflow tract was dissected all the way down initially with Metzenbaum scissors and then with cautery at low setting. This was done around the annulus to make sure we were below the nadir of both leaflets. A right angle clamp was passed to make sure that we were low enough. Once we were happy with the dissection, leaflet assessment was performed, and the prolapsed leaflet was plicated. This required two 6-0 Prolene sutures. A line between the two nadirs was drawn, and the height between this line and the commissure corresponded to the graft size that we used in this case. This was followed by sub-annular pledgeted suture placement. Two 4-0 pledgeted Prolene sutures were placed in the commissures for commissural suspensions. A total of 8 sub-annular sutures were placed. A Valsalva graft was used, the lower two rings were trimmed, and all the sub-annular sutures were passed through the graft. The commissural suspension stitches were passed into the graft in preparation for sliding the graft down into the aortic root. Proper placement of the graft was ensured and the graft was tied down. The commissures were suspended at the appropriate height. The secondary hemostatic layer was done by starting two suture lines from the nadir to the commissure on each side of each leaflet. A water test confirmed a competent aortic valve. The left coronary button was anastamosed using a 6-0 Prolene suture. Once this was concluded, a cardioplegia needle was placed and the root was pressurized again and suture lines were tested. Distal anastomosis was performed in a regular fashion and was reinforced with the Teflon strip. This was followed by right coronary button anastamosis to the graft. 6-0 Prolene was also used for this anastomosis. A cardioplegia needle was placed in the graft for plegia and de-airing. The clamp was removed and the patient was weaned from cardiopulmonary bypass. Hemostasis was achieved. Echocardiogram confirmed a competent valve with a good zone of coaptation.
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