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.