Ann Thorac Surg 2002;73:1986-1987
© 2002 The Society of Thoracic Surgeons
How to do it
Double valve replacement through an aorto-annulo-atriotomy using an aortic-valved graft in a mitral position
Richard Bauset, MD*a,
François Dagenais, MDa
a Cardiac Surgery, Québec Heart Institute, Laval Hospital, Sainte-Foy, Québec, Canada
Accepted for publication February 17, 2002.
* Address reprint requests to Dr Bauset, Department of Cardiac Surgery, Hôpital Laval, 2725 Chemin Sainte-Foy, Sainte-Foy, Québec, G1V 3B4, Canada
e-mail: richard.bauset{at}chg.ulaval.ca
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Abstract
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We present a modified technique for the reconstruction of the intervalvular fibrous body in double-valve replacement through an aorto-annulo-atriotomy. This technique allows the surgeon to enlarge and reconstruct both annuli by using a tailored aortic-valved conduit in a mitral position.
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Introduction
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Double (aortic and mitral) valve replacement or reoperation can be a challenging technical exercise. With small or calcified annuli, extensive destruction caused by infection, or multiple reoperations, sometimes replacement of both valves using conventional incisions is merely impossible. An operation through a continuous aorto-annulo-atriotomy provides exceptional exposure and allows annular enlargement and extensive tissue debridement. This technique has already been described by Najafi and Somers [1] and David and colleagues [2]. We propose a modification in which the reconstruction is done by using a tailored aortic-valved conduit for the mitral valve replacement.
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Technique
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An oblique aortotomy is carried down to the mid portion of the noncoronary sinus. A second incision starting on the left atrium dome at the level of the superior vena cava is directed toward the aortic incision up to the level of the annulus. Both native valves or prostheses are excised and tissues are debrided as needed. In the technique described by Najafi and Somers [1] and David and colleagues [2], a mechanical mitral valve prosthesis was used in a mitral position. Instead, we use an aortic-valved conduit (SJM Masters Series; St. Jude Medical, St. Paul, MN) from which we trim over two thirds of the graft’s circumference with an ophthalmic cautery (Fig 1).
The residual prosthetic graft will serve to anchor the noncoronary sinus sutures of the aortic valve (Fig 2A)
and enlarge the aortotomy closure. The graft will also serve to anchor a bovine pericardium patch used to close the left atrium dome (Fig 2B). This technique creates a secure attachment for the valve (SJM Masters Series aortic valve; St. Jude Medical) in the aortic position on a prosthetic aortic curtain. It also eliminates the need for a separate patch to close the aortotomy, thereby creating a more hemostatic reconstruction. The proper orientation of the valve in a mitral position should be double-checked before anchoring the aortic valve prosthesis to the conduit graft extension. This incision, with the reconstruction used, allows the surgeon to enlarge both annuli and insert the valve prosthesis at least two sizes larger than the native annuli.
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Fig 2. (A) Final reconstruction. (B) Final reconstruction. Arrows indicate flow direction. (AV = mechanical aortic valve in aortic position; AVG = tailored aortic-valved graft in a mitral position; LA = left atruim; LV = left ventricle; P = pericardial patch to close the left atrial dome.)
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We have used this technique in 2 patients over a 12-month period out of 28 double-valve replacements. The technique was used mainly to enlarge both annuli in patients who had previous valve replacements with early generation mechanical valves. Both patients survived the operation without complications.
Although used infrequently, this technique has proved very useful in the surgical treatment of complex valvular disorders.
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Acknowledgments
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We would like to thank Ms. Cécile Bilodeau and Ms. Martine Fleury for their technical assistance.
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References
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Najafi H., Somers J. Mitral and aortic annular enlargement for insertion of adequate prosthetic valves. J Card Surg 1993;8:472-475.[Medline]
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David T.E., Kwo J., Armstrong S. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body. J Thorac Cardiovasc Surg 1997;114:766-772.[Abstract/Free Full Text]
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Abstract
Introduction
