Methods
Demographic, intraoperative, and outcome data were collected
retrospectively cohort comparative study on (100) patients undergoing
DVR with or without ARE at a multicenter institutions between Jan. 2016
– Sept. 2020. Those patients with pure or predominant aortic valve
stenosis have been included in the study. One-hundred patients with
small AA were performed DVR, only (50) patients were underwent ARE with
DVR. Mean age was 35±20 years. Operative death and residual gradient on
prosthetic aortic valve (AV) were evaluated. Inclusion
criteria: Double valve replacement - Small aortic annulus- Rheumatic
heart disease - Adult age. Exclusion criteria: Valvular heart
lesions other than rheumatic disease - Isolated aortic valve replacement
– Children - Associated procedures other than DVR - Renal failure-
Emergency - Re operation.
A median sternotomy was performed in all patients. Cardiopulmonary
bypass (CPB) with systemic cooling to 32°C was routinely used. After the
aorta is cross-clamped (Ao.CC) and the heart is arrested by means of
intermittent, antegrade cold blood cardioplegia directly delivered into
coronary ostia. The decision to maximize EOA was made after
intra-operative assessment of AA. After debridement of aorta annulus, it
was sized and if it was not admitting 19 mm valve or not suitable to
BSA, aortotomy incision is extended into the fibrous trigone between NCC
and LCC [Manouguian ] or extended into NCC
[Nick′s ] to enlarge AA. This incision reconstructed using a
tear drop shaped patch of autologous pericardium [Pericardial patch
was harvested and fixed with glutaraldehyde] or bovine pericardium or
Dacron patch. Patch was sutured with 4/0 polypropylene starting at the
nadir of annular enlargement incision and extending up to 2–3 cm above
the plane of annulus. After replacing the mitral valve, AA was resized
and appropriate valve was chosen. We use a non-everting, horizontal
mattress technique of 2/0 polyester were placed on annulus. Pledgeted
sutures were placed in the plane of annulus where patch enlargement was
performed with pledgets resting on outside of the patch. After replacing
the valve patch, it was sutured to aortotomy margins using 4/0
polypropylene.
Simplified Manouguian which was allowed ARE without opening LA, without
distorting the mitral annulus, and decreased incidence of potential
bleeding. Also, modified Nick′s procedure was allowed ARE without
extended to mitral annulus , and can be performed in DVR.
In cases of small AA accepted small prosthetic AV without ARE, we have
started to implant AV after put pledgets along the mitral annulus before
implanting AV. So, AA gets the size of the valve that it deserves. Then
one can easily implant mitral valve. For better hemodynamic effect, we
prefer to implant prosthetic AV in anteroposterior direction. We prefer
to implant prosthetic mitral valve in anatomical position, so that
struts of mitral valve do not impinge upon AV, which is already in
position.