Technique
The surgical technique is illustrated in the Video (Video 1,
supplementary material). A transverse aortotomy is performed 1.5cm above
the origin of the right coronary artery, after the heart is arrested
with normothermic blood cardioplegia. The valve is assessed and
confirmed to be unicuspid with a true posterior commissure at the
left/non-coronary commissural position, and two raphae at the
non/right-, and right/left-position (Figure1C,D) . The height of
both raphae is below the height of the true posterior commissure. An
additional unusual finding is a diastasis of the posterior commissure,
which had to be addressed separately (Figure2C). Although the
aortic root is only moderately enlarged at 4.2cm, we performed our
modified reimplantation technique, since it provides the best
stabilization of the functional aortic annulus, with an excellent aortic
annuloplasty and support of the Sino-tubular junction7.
The aortic root is prepared and annular sutures are placed at the level
of the virtual basal ring as previously described by our group7. A commissurotomy is then performed at the
non/right-raphe to create a second functional commissure, and the free
margins are thinned with a blade (Figure2A,B) . The remaining
raphe is then shaven and thinned towards the hinge point of the anterior
cusp, to allow for better mobility (Figure2C) . Attention has to
be paid towards not accidentally perforating the cusp at its’ insertion.
The commissural diastasis of the posterior commissure is then addressed.
The commissure is incised towards its’ tip, in order to readjust the
width and to exclude some abnormal tissues in-between the cusps. The
commissure is then remodeled with a 4.0 Prolene suture(Figure2D) . This resolved the commissural diastasis and excluded
the abnormal tissues in-between the cusps and led to improved apposition
of cusp free margins.
A 30mm Valsalva-graft is then seated onto the aortic annulus and tied
down. The commissure and modified raphe are resuspended at 180º. The
nadir of the fused cusp, at the raphe, is lowered to match the nadir of
the non-fused cusp (Video1) . The graft is then sewn to the
proximal aortic root remnant and the aortic valve is re-assessed
thereafter. The anterior cusp is prolapsed and the neo-commissure is
lower than the posterior commissure. We usually perform central cusp
plications to treat a prolapse, but due to the good quality of cusp
tissues in proximity to the neo-commissure, and the bulk of tissues
centrally, we opted to perform a lateral cusp plication instead. This
lateral plication at the neo-commissure can also help to somewhat
elevate the commissure, if at the same time a small bite of the aortic
wall is taken laterally(Figure3A,B). In addition to this, the
neo-commissure was further resuspended, 5-10mm higher to match the
height of the posterior commissure, utilizing a 5.0 Prolene suture with
emphasis on the anterior prolapsing cusp (Figure3C,D). This is
feasible, due the good quality and large amount of cusp tissues, as well
as the annuloplasty, which increases cusp mobility due to a relative
increase of free margin length.
There was good coaptation, with an adequate effective- and geometric
height thereafter. Both coronary buttons were then reimplanted in the
usual fashion, and the distal aortic anastomosis was performed,
resecting the diseased aorta and wrapping the very distal ascending
aorta with a piece of prosthetic graft.