DR NIKUNJR SHEKHADA (MBBS,MS GEN SURGERY,DNB CTS RESIDENT)

1. AORTIC VALVE REPLACEMENT, AORTIC VALVE REPAIR
BY DR NIKUNJ
(CTS RESIDENT STAR HOSPITAL)
(Coordinator:DR P.SATYENDRANATH PATHURI)
(9/8/19)

5. AORTIC VALVE REPLACEMENT
Sharp excision of the aortic valve is performed using a #11 blade, starting with the right coronary cusp.

6. Aortic valve exposure through a transverse aortotomy aided by three commissural sutures (arrows) and a suture retracting the
distal portion of the ascending aorta cephalad.

7. Sizing of the appropriate aortic valve prosthesis using commercial sizers can be accomplished before (as depicted in this picture) or after valve excision.

8. • Alternating green and white valve sutures are systematically passed through the aortic valve annulus and then through the sewing ring of the prosthetic valve traveling from the
commissure between the left and right coronary cusps to the commissure between the left coronary and noncoronary cusps.

9. • All valve sutures have been placed around the annulus and through the sewing ring of the valve.

10. • The prosthetic valve is parachuted down into position by the surgeon who holds one set of valve sutures and the prosthetic valve along with the valve holder. The assistant holds
the other two sets of valve sutures. The surgeon and assistant pull on the valve sutures while the surgeon parachutes the valve down into position.

11. • Picture of prosthetic aortic valve in position after tying all valve sutures systematically beginning with the left coronary cusp, followed by the right coronary cusp, and then the
noncoronary cusp.

12. • Closure of the aortotomy can be performed using a one- or two-layer technique.

13. AORTIC ROOT ENLARGEMENT
• In patients with a small aortic annulus, implanting a small stented bioprosthetic valve or a mechanical valve
may leave residual gradient across the aortic valve.
• Forcing a small prosthetic valve may result in perivalvular leak or disruption of the aorta or left ventricle.
• POSTERIOR ENLARGEMENT of the aortic root is performed by either the Nicks-Nunez or the Rittenhouse-
Manouguian technique,
• ANTERIOR ENLARGEMENT is performed using the Konno- Rastan aortoventriculoplasty technique

14. NICKS-NUNEZ TECHNIQUE
• a vertical incision through the commissure between the left coronary and noncoronary cusp and extending down in the interleaflet triangle, followed by patch reconstruction of
the aortic root. This method can enlarge the aortic root by 2-3 mm.

15. • A diamond-shaped patch of autologous pericardium or prosthetic material is fashioned. One end of the patch is inserted into the distal end of the enlargement using interrupted
sutures with pledgets. At the level of the aortic annulus the sutures are passed through the sewing ring of the prosthetic valve. The remainder of the valve sutures are placed
through the aortic annulus in a standard fashion.

16. • The diamond patch is then tailored for closure of the aortotomy. If a transverse aortotomy is used, then the patch is transected at the level of the transverse aortotomy and
incorporated as part of the anastomosis of the aortic root to the ascending aorta.

17. • Rittenhouse-Manouguian Technique
• vertical incision through the middle of the noncoronary sinus extending through the annulus and into the anterior leaflet of the mitral valve.

18. KONNO-RASTAN METHOD OF AORTIC ROOT ENLARGEMENT
• In the Konno-Rastan method of aortic root enlargement, an incision is made through the right coronary region of the aortic annulus, near the commissure between the left and
right coronary cusps. The incision is carried further into the interventricular septum, and a similar incision is made on the right ventricular free wall.

19. • One end of a diamond patch is sewed to the deep end of the incision in a continuous fashion to repair the inter- ventricular septum up to the level of the aortic annulus.

20. • The base of a triangular patch is attached using interrupted pledgeted mattress sutures to the diamond patch at the level of the annulus. The same sutures are also passed
through the sewing ring of the prosthetic valve.

21. • The triangular patch is then folded to cover the right ventricular outflow tract defect and sewed using continuous running suture. The left ventricular outflow tract patch is finally
used to close the vertical aortotomy using continuous suture technique.

22. EL KHOURY CLASSIFICATION

23. EXPOSURE AND ASSESSMENT
• Full-thickness 4-0 polypropylene traction sutures are placed at the three commissures and retracted using
clamps, but not tied, to permit a dynamic assessment of valve anatomy.
• Leaflets are inspected to assess mobility, restriction, calcification, and prolapse.

24. RECONSTRUCTIVE TECHNIQUES
• TYPE I—AORTIC VALVE REGURGITATION
• Aortic valve regurgitation with normal leaflet motion is rare and often amenable to valve reconstruction. The
techniques vary depending upon the lesions.

25. • Isolated Aortic Annular Dilatation :
• rare , However, it may occur in dilated cardiomyopathy and in rheumatic valvular diseases, causing mild to
moderate regurgitation in association with concomitant mitral valve dysfunction.
• If the leaflets display minimal thickening and/or retraction, a circular annuloplasty is carried out to ensure
adequate leaflet coaptation.

26. LEAFLET PERFORATION
• The defect is usually limited and displays a healed fibrotic edge (a). This condition is favorable for valve
reconstruction by patching using glutaraldehyde-treated autologous pericardium (b)
• The patch is tailored according to the shape and size of the defect, adding a 2-mm margin for suturing.
• It is then sutured to the edge of the defect using 5-0 monofilament interrupted sutures tied on the aortic
side of the leaflet.
• In the presence of a large defect, continuous suture can be used provided that narrow or locked bites are
employed to avoid a purse-string effect.

27. VEGETATIONS
• Small and pedicled vegetations can usually be sharply excised with scissors without producing a perforation .
• Larger vegetations must be resected and the valve repaired by patching.
• In all instances, the ventricular aspect of the mitral valve should be carefully inspected to detect potential
kissing lesions

28. LEAFLET TEAR OR AVULSION
• The most favorable lesion is a tear of the belly of the leaflet that leaves the commissural areas intact (a).
• This type of lesion treated by direct suture.
• If a significant lack of tissue is present, the patch is secured to the edges of the tear (c).
• Leaflet avulsion is best treated by pericardial patching.

29. TYPE II—AORTIC VALVE REGURGITATION
• Type II aortic valve regurgitation may be corrected by reconstructive techniques, particularly when the
prolapse is limited and involves only one leaflet as in some congenital malformations or rheumatic valve
diseases.
• Since the mechanism of prolapse is usually a distension of the free edge of the leaflet, appropriate tension
can be restored by a triangular resection
• The amount of triangular resection is calculated by measuring the length of the free margin of the
corresponding halves of the adjacent leaflets and adding 2 mm on each side of the triangle for suturing (b).

30. TYPE IIIa—AORTIC REGURGITATION
• Type IIIa aortic regurgitation may result from rheumatic valvular disease, valve sclerosis, or bicuspid valve
malformation with commissural fusion.
• Whenever the amount of leaflet tissue is adequate with preserved pliability, leaflet mobilization by
commissurotomy can be attempted.
• The commissurotomy should ideally remove a wedge of fibrous tissue.

31. • TYPE IIIb—AORTIC VALVE REGURGITATION: VALVE SPARING
• In patients with isolated sinotubular junction dilatation and well-preserved leaflets, a supracoronary tube
graft interposition is often sufficient to correct aortic valve regurgitation.
• The goal of the procedure is to restore the normal ratio between the circumference of the sinotubular
junction and the aortic annulus. In those patients with extended aortic root dilatation, aortic valve sparing
procedures such as those described by Yacoub and David are an excellent indication.

32. SUBCOMMISSURAL ANNULOPLASTY
A subcommissural annuloplasty(Cabrol stitch) reduces the width of the interleaflet triangle, improves cusp coaptation, and can help to stabilize the
ventriculoaortic junction

33. VALVE-SPARING ROOT REPLACEMENT: REIMPLANTATION TECHNIQUE
• A valve-sparing root replacement using the reimplantation technique provides the most stable form of
functional aortic annuloplasty.
• Originally pioneered by David and colleagues, multiple modifications of this procedure have been reported.

34. • T. David-I Reimplantation with cylindrical tube graft (1988)
• T. David-II Yacoub remodeling
• T. David-III Yacoub remodeling + NCC external annuloplasty
• T. David-IV Reimplantation with 2-4mm larger graft + narrowed distal end (“STJ”)
• T. David-V Reimplantation with ~4-6mm larger graft + necking down both annular end & STJ (May 2001)
• T. David-V Stanford modification Reimplantation with 6-8mm larger proximal graft + necking down annular end + small
distal graft (December 2002)

35. AORTIC ROOT PREPARATION
• dissect the aortic root externally as low
as possible, given the natural anatomic
limitations (i.e., where the root inserts
into ventricular muscle).
• The root dissection is started along the
NC sinus and continued towards the
LC/NC commissure
• Moving toward the RC/NC commissure
and along the right sinus and the
RC/LC commissure,
• The sinuses of Valsalva are then
resected leaving approximately 5 mm
of aortic wall attached and the
coronary buttons are harvested.

36. PROSTHESIS SIZING
• a Hagar dilator is used to size the circle that includes
the three commissures, and a graft 4 mm larger is
chosen as this graft will sit outside the commissural
posts.
• height of the commissure (measured from the base
of the interleaflet triangle to the top of the
commissure) is equal to external diameter of the
sinotubular junction.
• The height of the commissure is most easily
measured at the NC/LC commissure by first drawing
a connecting line between the nadirs of the two
adjacent cusps (base of interleaflet triangle) and
measuring the distance between this line and the
top of the commissure.
• This height corresponds to the diameter of the graft
chosen.

37. PROXIMAL SUTURE LINE
• 2-0 Tycron sutures with pledgets are passed from inside to outside the aorta with the pledgets on the
inside, starting from the NC/LC commissure and moving clockwise.
• Along the fibrous portion of the aortic annulus, these sutures are inserted along the horizontal plane
formed by the base of the inter-leaflet triangles.

38. PROSTHESIS PREPARATION AND FIXATION
• A Dacron prosthesis with or without builtin
neoaortic sinuses can be used.
• The three commissures are attached to the
prosthesis along the same plane the new
sinotubular junction.
• First, the distance from the base of the
interleaflet triangle to the top of the
commissure is measured at the LC/NC
commissure and marked on the graft.
• Next, at the RC/NC and RC/LC commissures, the
distance from the proximal suture to the top of
the commissure is measured and used to
determine the amount of graft material that
needs to be trimmed .
• The pledgeted sutures are then passed through
the base of the prosthesis, respecting the spaces
between sutures and the curvilinear contour of
the suture line.

39. VALVE REIMPLANTATION.
• The commissures are reimplanted first using 4-0 polypropylene sutures while pulling up on the prosthesis
and the native commissure and then tied into place.

40. LEAFLET ASSESSMENT AND REPAIR
• reexamine the leaflets for any unmasked prolapse, symmetry, and the height and depth of coaptation.
• Cardioplegia is administered through the distal end of the graft with partial clamping to distend the new
aortic root and to assess root pressure and signs of LV dilation.
• The cardioplegia solution is then slowly aspirated out of the prosthesis without distorting the leaflets.
• This gives another visual assessment of the aortic valve in its physiologic closed state as well as the area and
height of coaptation.
• Coronary ostia are then reimplanted on the graft, and the distal anastomosis is performed at the level of
normal aorta.

41. CUSP REPAIR TECHNIQUES
• Cusp prolapse is the most frequently encountered lesion and is associated with excess length of the free
margin, which can be corrected using either central free margin plication or free margin resuspension.
• When a single cusp is prolapsing, the two nonprolapsing cusps serve as the reference and are used to
estimate the required reduction in the free margin length.
• When two cusps are prolapsing, the third nonprolapsing cusp is used as a reference to indicate the desired
height of coaptation.
• In the rare instance that all the cusps are prolapsing, the goal is to achieve a cusp coaptation height at the
midlevel of the sinuses of Valsalva.

42. FREE MARGIN PLICATION

43. FREE MARGIN RESUSPENSION

44. EARLY COMPLICATIONS
• Neurologic Complications
• transient ischemic attacks (TIAs), which are fully reversible neurologic events lasting less than 24
hours;
• reversible ischemic neurologic deficit, which are fully reversible neurologic events lasting between 24
hours and 3 weeks;
• strokes, which are nonreversible neurologic deficits lasting longer than 3 weeks
• The rate of stroke for isolated AVR, according to the STS database, is 1.5%.
• In high-risk (STS predicted risk of mortality > 10%) and older patients (>80 years old), the risk of stroke
rises to between 2% and 4.4%.
• The addition of CABG to the AVR also raises the risk to between 4.9% and 5.8%. Risk factors for early
postoperative stroke include low LVEF (<40%), ascending aortic calcification, older than 70 years,
female sex, diabetes mellitus, bypass time greater than 120 min
• a history of stroke, carotid artery disease, and walking less than 300 meters during a 6-minute walk
test.

45. HEART BLOCK AND PERMANENT PACEMAKER IMPLANTATION
• Atrioventricular node block occurs more frequently after heart valve surgery compared with other types of
cardiac surgery, with 3% to 8% of patients requiring permanent pacemaker insertion.

46. LATE COMPLICATIONS
• Thromboembolism, Anticoagulation, and Bleeding Complications
• Fluctuations in the international normalized ratio (INR) seem to be an important risk factor for both
thromboembolic and bleeding events
• close monitoring of the INR to minimize fluctuations may be important to prevent these complication
• Anticoagulation with a minimum target INR of 2.0 to 3.0 for low-risk patients and valves with low
thrombogenicity is recommended for mechanical AVR
• On-X Anticoagulation Clinical Trial (PROACT) suggest that INR may be safely maintained between 1.5 and 2.0
with lower risk of bleeding and without a significant increase in thromboembolism
• The target INR should be 2.5 to 3.5 for patients at high risk for thromboembolism or who receive mechanical
valves with high thrombogenicity (disc valves).

47. PROSTHETIC VALVE ENDOCARDITIS
• early PVE if it occurs less than 60 days post implantation and
• late PVE if it occurs more than 60 days post implantation.
• The rate of PVE is approximately 0.5% to 1% per year, with a slightly higher rate in the first 6 to 12
months compared to less than 12 months.
• Early PVE is usually a result of perioperative seeding of the prosthetic valve either intraoperatively or
from wound infections or indwelling intravascular catheters postoperatively.
• Late PVE usually results from noncardiac sources of bacteremia or some- times from insidious
infections with less virulent organsms introduced perioperatively
• Early PVE is associated with 30% to 80% mortality, whereas late PVE is associated with 20% to 40%
mortality

48. PARAVALVULAR LEAK AND HEMOLYSIS
• The continuous suture technique of aortic valve implantation was traditionally thought to be a risk factor for
paravalvular leak compared with an interrupted suture technique.

49. PROSTHESIS-PATIENT MISMATCH
• The persistence of left ventricular outflow obstruction postoperatively is termed prosthesis-patient
mismatch (PPM)
• effective orifice area (EOA) indexed to the patient’s body surface area indexed effective orifice area (IEOA)
• The EOA is measured by echocardiography using the continuity equation or by cardiac catheterization using
the Gorlin formula.
• An IEOA of 0.65 to 0.85 cm2/m2 is generally defined as moderate PPM, and less than 0.65 cm2/m2 is
defined as severe PPM.
• The prevalence of moderate PPM ranges from 20% to 70% and severe PPM ranges from 2% to 11%.

51. BICUSPID AORTIC VALVE REPAIR
• Type 0 bicuspid aortic valve do not contain a median raphe, have two symmetric aortic sinuses, two commissures, and a
symmetric base of leaflet implantation of the two cusps.
• The mechanism of AI in this setting is usually cusp prolapse of one or both cusps because of the presence of excess cusp
tissue.
• Type 1 bicuspid aortic valve, have a median raphe on the conjoint cusp and an asymmetric distribution of the aortic
sinuses, with a large aortic sinus accompanying a large nonconjoint cusp and two smaller cusps fused together with a
median raphe.
• The raphe often attaches to the cusp base in the form of a “pseudocommissure,”
• The raphe may be restrictive, fibrotic, calcified, or prolapsing.
• The mechanisms of AI in type 1 valves can be due to a rigid and restrictive raphe associated with small fused cusps
resulting in a triangular coaptation defect.
• Alternatively, the raphe may be short and nonrestrictive with well-developed cusps and associated prolapse of the
conjoint cusp.

52. • In type 0 valves, the degree of prolapse is assessed by comparing the prolapsing cusp to the nonprolapsing
cusp, similar to trileaflet valves.
• If both cusps are prolapsing, the goal is to restore the height of coaptation to the midpoint of the sinuses of
Valsalva.
• This can be performed using free margin plication, free margin resuspension with 7-0 PTFE suture, or both as
previously described for trileaflet valves.
• Thickened, fibrotic areas of the leaflet (typically central aspect of the free margin) are shaved, and localized
decalcification is performed if calcium is present.

53. • In type 1 valves, the median raphe is addressed first.
• If the raphe is relatively mobile and only mildly thickened and fibrosed, it is preserved and shaved using a combination of a
scalpel and scissors When a severely restrictive or calcified raphe is present, a parsimonious triangular resection of this
tissue is performed
• Next, the quantity of remaining cusp tissue is assessed by putting the two arms of a 6-0 polypropylene suture on the free
margin of the conjoint cusp, on either side of the resected raphe.

57. UNICUSPID AND QUADRICUSPID AORTIC VALVES
• unicuspid and quadricuspid are rare variants of aortic valve anatomy, and both can manifest with either
valve stenosis or insufficiency.
• The most common approach to the repair of the regurgitant unicuspid valve involves bicuspidization by
creating a neocommissure using a pericardial patch.
• Techniques using a single or double patch have been described
• These repairs are typically performed in the pediatric or young adult population, and long-term data on
valve durability are lacking.

58. THANK YOU