Matthew Janko MD and Joseph Sabik III MD
University Hospitals, Case Western Reserve University, Cleveland, Ohio, USA
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by Walter F. DeNino, MD and John S. Ikonomidis, MD, PhD.
Essential Operative Steps
- Preoperative TEE assessment of the heart
- Lines and monitoring
- Sternotomy and creation of pericardial well
- Heparinization
- Ascending aorta and right atrial cannulation for CPB, placement of antegrade/retrograde cardioplegia cannulae, and LV
vent - Aortic crossclamp and antegrade arrest
- Transverse aortotomy
- Direct visual assessment of the aortic valve
- Dissection and preparation of the aortic root and coronary buttons
- Hegar dilator for graft size selection
- Creation of the neo-aortic root using polyester graft
- Testing of the aortic valve for competence
- Closure of aortotomy and deairing
- Wean from CPB
- Assessment of valvular function by TEE (aortic valve replacement if necessary)
- Place chest tubes/drains, pacing wires, remove cannulae, close chest
Potential Complications and Pitfalls
- Injury to conducting system near commissure of left and non-coronary aortic valve leaflets
- One should aim for a cusp coaptation length of 5mm or more for durable repair. Any more than trivial insufficiency,
consider re-arresting the heart and inspecting the repair. If the reason for valve insufficiency is not identified or not
repairable, it may be necessary to replace the aortic valve with either a mechanic or tissue prosthesis based on patient
preference
Template Dictation
Preoperative Diagnosis: Aortic root aneurysm with aortic valve regurgitation
Postoperative Diagnosis: Same (with appropriate adjustments)
Indication for Procedure: [AGE] year old [SEX] who was found to have a dilated aortic root with a diameter greater than
5.5cm. A previous preoperative echocardiogram showed a trileaflet aortic valve which was completely competent one year
ago, now with development of central aortic regurgitation. Of note, the aortic root growth rate is greater than 0.5 cm in one
year. The patient underwent preoperative coronary angiogram ruling out any significant coronary disease. Additional crosssectional imaging revealed no other dilatation of the aorta.
Procedures Performed:
- Median sternotomy
- Cardiopulmonary bypass via ascending aortic and right atrial cannulation
- Aortic valve-sparing aortic root replacement using [NUMBER]mm woven polyester graft
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia Type: [BLANK]
Description of the Procedure: The patient was taken to the operating room on [DATE] and placed upon the operating table
in the supine position. A safety pause was performed in the presence of the entire operating room team including the attending
surgeon, attending anesthesiologist, nurses, and perfusionists. The patient’s identity and operative plan were confirmed with
the entire operating room staff.
General anesthesia was induced, and a brachial artery line was inserted. Preoperative TEE was performed. The patient was
prepped and draped in the usual sterile fashion. A median sternotomy was performed. The thymus was divided, and the
pericardium was opened. There were no pericardial adhesions or effusions. The ascending aorta was palpated, and it was soft
without evidence of atherosclerosis. Unfractionated heparin sulfate was administered intravenously, and the activated clotting
time was noted to be >480 seconds. The ascending aorta and right atrium were individually cannulated. CPB was initiated and
the mid-anterior ascending aorta was cannulated. A retrograde cardioplegia cannula was placed through the lateral right atrium
and the coronary sinus was intubated. The aorta was crossclamped and antegrade and retrograde cardioplegia were given,
resulting in diastolic cardiac arrest. The heart was maintained in the arrested state with intermittent dosing of retrograde
cardioplegia every 15 minutes for the duration of the crossclamp time.
The ascending aorta was divided at the level of the main PA and direct visual inspection confirmed the echocardiographic
findings including the presence of a tricuspid aortic valve with minimal leaflet disease. The aortic root was dissected with
preservation of the commissures and aortic wall rim around the aortic valve leaflets. Both coronary ostia were separated from
the aortic wall and dissected away from the root for later reimplantation. The aortic annulus was measured with a Hegar dilator
and a [NUMBER]mm woven polyester graft was brought to the table, which was 6mm larger than the measured annular
diameter. [OPTIONAL: Multiple 5-0 braided polyester interrupted stitches were placed along the proximal graft edge to
evenly plicate to the size to the annulus]. Multiple 2-0 braided polyester non-absorbable stitches with small pledgets were used
to secure the aortic root to the graft, and these were passed from the subvalvular area through the aortic wall into the graft from
inside out and tied with the Hegar dilator placed in the annulus to avoid annular constriction. The freed commissures were
positioned at 120o of separation using pledgeted 4-0 polypropylene stitches through the commissure and graft and tied outside.
The annular stitches were also sutured to the graft, and the rim of the coronary sinus was sutured to the graft using an in and
out stitch around the 3 sinuses with the stitches being tied at the level of every commissure. At this point the valve was examined
and was [TYPE: perfectly competent or incompetent requiring further aortic valve repair or replacement]. The left coronary
neo-ostium was created using cautery on the polyester graft and the left coronary button was reimplanted tension-free with a
continuous 5-0 running polypropylene suture [OPTIONAL: with felt or pericardial strip reinforcement]. Similarly, the right
coronary button was reimplanted. Mild hypothermia was reversed to normothermia while warm blood was delivered via the
coronary sinus. [OPTION: The graft was cut to reach the proximal aortic arch immediately proximal to the innominate artery
and the final anastomosis was performed with a 4-0 running polypropylene suture; OR a (5mm smaller) woven polyester graft
was sewn to the proximal aortic arch immediately proximal to the innominate artery and thus created a neo-pseudosinus at the
anastomosis of the proximal and distal ascending aortic graft segments].
The ascending aortic vent was replaced onto the anterior graft, the left side of the heart was deaired, and the crossclamp was
removed. Temporary epicardial pacemaker wires were placed and tested to confirm function. The patient was noted to be in a
[TYPE: sinus, junctional, other] rhythm. The heart was partially filled and echocardiography revealed a [TYPE: competent or
incompetent] aortic valve. The patient was able to be separated from the bypass pump after [DURATION] minutes of
reperfusion with no issue, normal hemodynamics, and repeat echocardiography revealing normal valvular and ventricular
function. Heparin reversal was initiated with protamine and the patient was decannulated. Hemostasis was achieved and all the
counts were correct by the circulating nursing team. Two chest tubes were placed into the mediastinal cavity. The sternum and
the wound were closed in the standard fashion. The patient was taken to the intensive care unit for recovery in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
Multiple Choice Question(s)
Which of the following is one of the common complications of valve-sparing aortic root replacement?
A. Heart block due to injury of the conducting system at the commissure between the right and non-coronary aortic cusps
B. Technical challenge with the annular and commissural stitches using the David-I technique
C. Aortic regurgitation due to David-I technique or if commissural height alignment is too low
D. Kinking and occlusion of the right coronary artery ostium
E. All of the above
Answer: E.
Sources
T. David, C. Feindel. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending
aorta. J ThoracCardiovascSurg, 103 (1992), pp. 617-622
Miller D. C. Valve-sparing aortic root replacement in patients with the Marfan syndrome. J Thor CardiovascSurg, 125
(2003), pp. 773-778
