Domenico Mazzitelli, MD, Steffen Pfeiffer, MD, J

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Presentation transcript:

A Regulated Trial of Bicuspid Aortic Valve Repair Supported by Geometric Ring Annuloplasty Domenico Mazzitelli, MD, Steffen Pfeiffer, MD, J. Scott Rankin, MD, Theodor Fischlein, MD, Yeong-Hoon Choi, MD, Thorsten Wahlers, MD, Christian Nöbauer, MD, Christian Schreiber, MD, Rüdiger Lange, MD The Annals of Thoracic Surgery Volume 99, Issue 6, Pages 2010-2016 (June 2015) DOI: 10.1016/j.athoracsur.2015.01.050 Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Geometric ring annuloplasty for bicuspid aortic valve repair. (A) Ring is shown superimposed on computed tomographic angiogram of a bicuspid valve with the location of transannular horizontal mattress sutures in blue. (B) Long-axis computed tomographic angiogram of repaired bicuspid valve with ring sutured into and positioned below the valve annulus. An ascending aortic aneurysm also has been replaced. (R-L = right-left.) The Annals of Thoracic Surgery 2015 99, 2010-2016DOI: (10.1016/j.athoracsur.2015.01.050) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Ring suture technique. With the ring on a holder above the valve, the two bicuspid posts are sutured to the subcommissural spaces using horizontal mattress sutures. Sutures are placed deeply into the aortic annulus,and they catch the Dacron on the inside of the post. Then the post sutures are tightened, and the ring is lowered below the valve. Finally, seven looping body sutures are passed up through the annulus, three in the nonfused and four in the fused annulus. The Annals of Thoracic Surgery 2015 99, 2010-2016DOI: (10.1016/j.athoracsur.2015.01.050) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Sequential steps in bicuspid aortic valve repair with bicuspid ring annuloplasty. (A) Dilated bicuspid annulus during ring implantation. Both post/commissural sutures have been placed and the ring lowered below the valve. (B) Completed ring annuloplasty showing annular reduction and assumption of 50% to 50% circular geometry. The leaflets have been moved centrally by the annuloplasty. (C) The nonfused leaflet has been plicated to an adequate reference effective height, and spacing sutures have been placed to define the size of the leaflet cleft. (D) After cleft closure, the leaflets coapt well with equal length and effective height [14]. The Annals of Thoracic Surgery 2015 99, 2010-2016DOI: (10.1016/j.athoracsur.2015.01.050) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) A long suture tail has lacerated the nonfused leaflet, necessitating reoperative aortic valve replacement. (B) An autologous pericardial leaflet has been lacerated by a long annular suture tail (the suture tail is evident above the tear, pointing straight at the leaflet hole) Arrows indicate leaflet tears. The Annals of Thoracic Surgery 2015 99, 2010-2016DOI: (10.1016/j.athoracsur.2015.01.050) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Technique to prevent suture untying and leaflet injury from long suture tails. (A) At the end of the procedure, the annular sutures are tied tightly with eight knots. (B) One or both needles are passed downward through the lateral aspect of the pledget, and the sutures are tied again. (C) After six more knots are tied, the suture tails are cut short. (D) At the end, the knot towers are sutured down and away from the fragile leaflets. The Annals of Thoracic Surgery 2015 99, 2010-2016DOI: (10.1016/j.athoracsur.2015.01.050) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions