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AORTIC VALVE REPLACEMENT

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ETIOLOGY

INDICATION FOR SURGERY

TECHNIQUES

RELATED PROCEDURES

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RELATED PROCEDURES

ROOT ENLARGEMENT

SEPTAL MYOMECTOMY

​STENTLESS & ALLOGRAFTS

​CONCOMITANT PROCEDURES

ROSS PROCEDURE

CONCOMITANT PROCEDURES

Aortic Valve  Replacement with Concomitant Ascending Aorta Surgery

Isolated Post-Stenotic Dilation of the Ascending Aorta (4.0–5.5cm):

• Optimal decision remains controversial. 
• Recommended strategies:

A. Isolated aortic valve replacement

• With subsequent echocardiography follow-up of the ascending aorta dimensions.
• Mostly in patients with a large body-surface area and an aortic diameter of approximately 4cm.

B. Supracoronary replacement of the ascending aorta with a prosthetic graft:

• With greater extent of aortic dilation, in younger patients and in the presence of local pathologies of the ascending aorta.

C. Wrap up (girdle) the ascending aorta with the prosthetic-graft fabric

• An acceptable solution in elderly, polymorbid patients and in patients with smaller aortic dilation.

D. Reducing aortoplasty with concomitant girdling; 

• A longitudinal aortotomy is needed to later enable the accomplishment of the aortoplasty.
• Aim to reduce the aortic diameter to at least 4cm
• Girdling  prevents further progression of aortic dilation.

Girdling of dilated ascending aorta

Supracoronary replacement of dilated ascending aorta

Supracoronary aortic replacement for poststenotic aortic dilation

Ascending Aortic Dilatation with Sinus of Valsalva and Sinotubular Junction (STJ) Involvement:
Bentall Procedure:

• Originally indicated for aortic incompetence at the annulo-aortic ectasia.
  
• Treatment of choice for aortic stenosis with dilated STJ and ascending aorta.
• Involves simaltaneous aortic valve replacement and ascending aortic replacement using a composite conduit (tube graft with a built-in valve prosthesis).

Technique:

• Aortic cross clamp is applied very close to the origin of the brachiocephalic trunk.
  
• The aneurysmal sac is opened.
  
• Explantation of the native aortic valve.
• Implantation of the composite graft with mattress pledgeted stitches or using continuous technique.
• Reimplantation of the coronoary bottons into the graft with a continuous stitch.
• Joining the distal end of the tube graft to the end of the ascending aorta.
• The aneurysmal sac is resected to the appropriate size and wrapped around the graft conduit:
  

              - Acts as a protection against graft infection
              - Achieve haemostasis when there is diffuse bleeding from the graft or minor inaccessible leaks. 

Cabrol Shunt:

• In case of persistent bleeding and blood accumulation inside the closed sac with resultant increased pressure  around the coronary ostia.
• Creating of a surgical formed shunt between:

              - The aneurysmal sac and the right artial appendage.
              - Graft interposition (Gore-Tex or savenous vein).

• This creates a temporary left to right shunt as the thrombose within several hours after heparin reversal and cessation of minor bleeding.

Valved composite graft. 
Modern types reproduce the geometry of sinuses of Valsalva (bottom)

Implantation of valved composite graft into aortic orifice with pledgeted mattress sutures

The Bentall procedure. 
Original technique with wrapping of the valved graft with the resected aneurysmatal sac

The Button Technique (Modified Bentall Procedure)

• Resection of the aneurysmal sac rather than wrapping it around the composite conduit.
• This technique was developed in response to the availability of zero-porosity vascular grafts (collagen or gelatin impregnated).

Modified Bentall Procedure (Button Technique)

Modified Bentall Procedure by Cabrol et al

• Inability to mobilize the coronary ostia to reach the conduit (firm adhesions in reoperations).
• 8 mm vascular graft inter-positioned in an arch-like connection between the coronary ostia and the prosthetic graft.

Svensson Technique:

• If only one coronary ostium is too far to reach the tubular graft.
• The interposed graft must follow a circumferential course before entering the tube graft to limit the risk of graft kinking. 

Cabrol Modification of Bentall Procedure

Cabrol technique for anastomosing coronary ostia with the vascular graft (operative view)

Svensson Modification of Bentall procedure with anastomosing the left coronary artery

Svensson technique for anastomosing right coronary ostium with the vascular graft (operative view). 

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