Ann Thorac Surg 1999;67:89-92
© 1999 The Society of Thoracic Surgeons
Original Articles
Intravalvular implantation technique for aortic valve replacement in aortitis syndrome
Yutaka Kotsuka, MDa,
Osamu Tanaka, MDa,
Shinichi Takamoto, MDa,
Akira Furuse, MDb
a Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan
b JR Tokyo General Hospital, Tokyo, Japan
Accepted for publication June 18, 1998.
Address reprint requests to Dr Kotsuka, Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Abstract
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Background. Paravalvular leakage is one of the most serious complications of aortic valve replacement in patients with aortitis syndrome. The purpose of this study was to compare the effectiveness of the intravalvular implantation technique in preventing paravalvular leakage with that of the conventional technique.
Methods. Since 1982, 14 patients with aortic regurgitation caused by aortitis syndrome have undergone aortic valve replacement at our institute. An intravalvular implantation technique was applied in 7 of the 14 patients. The technique consists of suturing a prosthetic valve to the aortic annulus and sandwiching the leaflets between exogenous felt pledgets and the inflamed aortic annulus.
Results. Paravalvular leakage occurred in 3 of 7 patients in the conventionally treated group and in none of 7 in the intravalvular implantation group.
Conclusions. The intravalvular implantation technique is effective in preventing paravalvular leakage in patients with aortitis syndrome.
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Introduction
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It is well known that aortic regurgitation is present in a relatively high percentage of patients with aortitis syndrome [1, 2]. Dilatation of the aortic root is the main cause of aortic regurgitation [3], although there are many cases in which the real cause of regurgitation cannot be elucidated. In most cases, the aortic valve leaflets themselves are normal or nearly normal [4, 5]. In other words, the syndrome is essentially an aortic disease but not an aortic valve disease.
Paravalvular leakage is one of the most serious complications of aortic valve replacement for aortitis syndrome, especially in the active phase of the disease [6, 7]. The major factor responsible for the high incidence of paravalvular leakage is persistent inflammation of the aortic annulus. In this regard, adequate control of the inflammation of the aorta and aortic annulus is considered essential for the prevention of paravalvular leakage [7, 8]. In some cases, however, the aortic regurgitation is so severe that the surgeon has to proceed with aortic valve replacement even at the uncontrolled active phase of the disease. There are also some patients in whom paravalvular leakage may occur despite apparently adequate control of the inflammation [8]. These findings led us to use the technical modification of suturing a prosthetic valve at the aortic position. In 1989 we described the intravalvular implantation (IVI) technique in a patient with the active phase of aortitis syndrome [9]. Since then, we have used this technique for patients with aortitis syndrome, especially when the inflammation was thought to be active. The purpose of the present study was to compare the effectiveness of the intravalvular implantation technique for prevention of paravalvular leakage with that for the conventional technique.
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Material and methods
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The study included 14 patients (age 35 to 64 years; mean, 53 years; 4 men, 10 women) with aortic regurgitation from aortitis syndrome who have undergone aortic valve replacement at the University of Tokyo Hospital since 1982 (Table 1). The aortitis syndrome activity was determined by serologic examination (C reactive protein test). Two patients were in the healed phase, and 12 were in the active phase. Nine patients were taking steroids to suppress inflammation. Cardiovascular lesions other than aortic regurgitation were atrioventricular block in 2 patients, left main trunk coronary artery lesion in 2, aneurysm of the ascending aorta in 1, annuloaortic ectasia in 1, and aneurysm of the Valsalva sinus in 1. The operative procedures were aortic valve replacement in 8 patients, aortic valve replacement plus coronary artery bypass grafting in 2, aortic root replacement in 1, aortic valve replacement plus wrapping of the ascending aorta in 1, aortic valve replacement plus aneurysmorrhaphy of the Valsalva sinus in 1, and aortic valve replacement plus pacemaker implantation in 1. All operations were performed under cardiopulmonary bypass with medium hypothermia and cardioplegic cardiac arrest.
The 14 patients were classified into two groups according to the surgical technique of aortic valve replacement. The conventional method was used in 7 patients (conventional group) and the IVI technique also in 7 (IVI group). The conventional technique included the usual everting mattress sutures using felt pledgets with or without transaortic mattress sutures from outside the aortic wall. The IVI technique is a modified everting mattress suture technique in which the aortic valve leaflets are placed between the felt pledgets and the aortic annulus. The details of this method (Figs 1, 2) are as follows: (1) After the oblique aortotomy, small parts of the aortic leaflets near the Alantius body are resected for pathohistologic examination, with most parts of the cusps left intact; (2) felt-pledgeted mattress sutures are passed through the aortic cusp near its free margin, from the ventricular side to the aortic side; (3) the needles are then pierced through the aortic annulus, from the aortic to the ventricular side, as in the usual everting mattress sutures; (4) the needles are finally passed through the sewing cuff of the prosthetic valve. In this modified method, therefore, the aortic cusps are interposed between the exogenous felt pledgets and the inflamed aortic annulus.
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Fig 1. Surgical technique of intravalvular implantation for aortic valve replacement. (AO = ascending aorta; LV = left ventricle.)
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Fig 2. Intravalvular implantation technique. The aortic cusps are sandwiched between exogenous felt pledgets and the aortic annulus. (LCC = left coronary cusp; RCC = right coronary cusp; NCC = noncoronary cusp; LCO = left coronary ostium.)
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All patients but 1 were followed up at our hospital or our affiliate hospitals, which resulted in a 93% follow-up rate. One patient was lost to follow-up 5 years after operation. The mean follow-up period was 5.6 years (range, 1 to 13 years). The mean follow-up period of the conventional group (6.7 years) was longer than that of the IVI group (4.6 years). Eleven patients were receiving steroids at hospital discharge. The mean dose of prednisolone was 12.3 ± 6.8 mg/day. During follow-up, the dose of prednisolone in each patient was changed to maintain the level of C reactive protein at less than 2 mg/dL. The diagnosis of paravalvular leakage was made on the basis of the results of the last ultrasound echocardiographic examination during follow-up.
A 
2 analysis was used to compare the incidence of paravalvular leakage between the conventional and IVI groups.
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Results
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Histologically, the inflammation of the aortic wall was active in 9 patients and healed in 5. As for the aortic leaflets, macroscopically remarkable changes, such as perforation, tear, cuspal fusion, or thickening, were not seen. Histologic examination of the leaflet revealed myxomatous changes in 11 patients and no or mild cell infiltration in all patients.
No in-hospital deaths occurred, but there were three late deaths (2 patients in the conventional group, 1 in the IVI group). The late deaths were due to cerebral bleeding, sudden death, and unknown causes and occurred 4, 7, and 7 years after operation, respectively. There were no cases of significant valve detachment that necessitated repeat valve replacement; however, small paravalvular leakage was revealed by ultrasound echocardiography in 2 patients and moderate leakage in 1.
The incidence of paravalvular leakage was analyzed according to the surgical technique of aortic valve replacement and was 0% (0 of 7) in the IVI group and 43% (3 of 7) in the conventional group (Table 1). Leakage occurred in 2 of the 3 patients who required transaortic sutures. Table 2 shows the incidence of paravalvular leakage according to inflammation activity as well as surgical techniques used. There were no cases of paravalvular leakage in either the healed phase or the IVI group. In other words, paravalvular leakage was found only in a subgroup of patients with active aortitis undergoing conventional valve replacement. The incidence of leakage was as high as 50% in this subgroup. The difference in overall incidence of leakage between the conventional and IVI groups was not statistically significant. However, in 12 cases of active inflammation, the incidence of leakage was lower in the IVI group than in the conventional group before Yates correction (p < 0.05), although the difference was not significant after correction.
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Comment
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Aortitis syndrome is one of the major causes of aortic regurgitation requiring valve replacement in Japan. At our institute, 13% of patients who underwent valve replacement for aortic regurgitation during the past 5 years had aortitis syndrome.
Dilatation of the aortic annulus is the major cause of aortic regurgitation in aortitis syndrome [1]. Although perforation or marked shortening of the aortic cusps has been reported in a few cases [10, 11], basic pathologic changes occur in the aortic wall and annulus rather than in the aortic cusps in most cases of aortitis syndrome. According to Isomura and colleagues [5], who reported 11 cases of aortic regurgitation secondary to aortitis, the aortic valve leaflets were normal in all patients. In our series, no patient had valve leaflets with severe inflammation leading to aortic regurgitation.
In patients with aortitis syndrome, paravalvular leakage or valve detachment and anastomotic false aneurysm are the most serious and frequent complications. Many cases of valve detachment after aortic valve replacement or aortic root replacement have been reported [5, 6, 8, 12–15]. The major factor responsible for the high incidence of paravalvular leakage in aortitis syndrome is persistent inflammation of the aortic annulus. For this reason, adequate control of inflammation is extremely important. However, there are patients with inflammation that is difficult to control before operation or in whom aortic valve replacement is necessitated during active inflammation resulting from hemodynamic deterioration. Such patients apparently require special surgical techniques to prevent postoperative paravalvular leakage.
We think that the IVI technique has two beneficial effects in preventing paravalvular leakage or valve detachment. One is the effective physical support provided by the pledgets. The other is the avoidance of direct contact between exogenous felt pledgets and the inflamed aortic annulus. The IVI technique has the effect of decreasing the pressure impact between the felt pledgets and the aortic annulus rather than directly decreasing the impact to the prosthetic valve. Cooley and Ingram [16] proposed a similar principle of "intravalvular implantation" of the prosthetic valve in both the mitral and aortic positions. They recommended the application of the technique in patients with a fragile valvular annulus. In our modified method, nearly normal aortic cusps are interposed between the exogenous felt pledgets and the inflamed aortic annulus. Although the least affected or normal aortic cusps are thin and soft, thereby providing only weak physical support, it is assumed that the avoidance of the direct attachment of foreign materials to the inflamed annulus has significant beneficial effects in preventing leakage. We consider this to be the most important feature of the IVI technique.
The present series was not large enough to demonstrate a statistically significant difference in the incidence of paravalvular leakage between the conventional and IVI groups. However, in view of many reports that have described valve detachment, the results of our study indicate that the IVI technique is effective in preventing valve detachment or leakage even in the active phase of the syndrome. We should, however, recognize a limitation of the technique. As described, inflammation is present in the valve leaflets as well as in the aortic wall in some cases of aortitis syndrome. In these cases, application of the technique may have a less beneficial effect in preventing paravalvular leakage. We believe that this technique is best indicated for patients with aortic regurgitation and aortitis syndrome in which the aortic wall and annulus are inflamed but the aortic cusps are apparently intact.
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References
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Abstract
Introduction
