Minimally Invasive Valve Sparing Aortic Root Replacement in a Patient With Marfan Syndrome
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Preoperative computed tomography of the chest showed an aortic root dilatation at the sinuses of Valsalva, which measured 5.5 cm. Transesophageal echocardiogram (TEE) demonstrated a trileaflet aortic valve with moderate aortic valve insufficiency. A 6 cm upper partial sternotomy incision extending to the right fourth intercostal space was performed. The aorta was transected 1 cm cephalad from the sinotubular junction. The aortic root was circumferentially mobilized to the level of the aortoventricular junction. The left and right coronary buttons were created and the noncoronary sinus was excised. A circumferential series of 2-0 Ethibond pledgeted annular sutures were placed through the annulus from beneath the aortic valve in a clockwise fashion, beginning at the noncoronary (NC)/left coronary (LC) commissure. These sutures were placed in a horizontal plane formed by the base of the interleaflet triangles between the NC and LC commissures, with exceptions of LC/NC and right coronary/NC areas.
The precise height of each commissure was measured, transposed onto the graft, and the graft was trimmed in these areas. The subvalvular annular sutures were passed through the aortic graft. The graft was positioned and fastened with an automated suture fastener device. The commissures were secured at the appropriate height within the graft with 4-0 pledgeted polypropylene suture. Subsequently, the circumference of the aortic valve apparatus was secured to the graft with running 4-0 polypropylene sutures. The competency of the aortic valve was reassessed. The left and right coronary anastomoses were performed using button technique. Finally, the distal anastomosis was completed. Postoperative TEE showed excellent hemodynamics, and the patient had an uneventful hospital course.
Minimally invasive valve sparing root replacement is beneficial in a patient with Marfan syndrome because the procedure eliminates the defective tissue, preserves the aortic valve, decreases trauma to an abnormal sternum, and provides an excellent overall result in a young patient.