Ann Thorac Surg 2005;79:1787-1789
© 2005 The Society of Thoracic Surgeons
How to do it
Repair of Aortic Leaflet Prolapse: The "Sliding Leaflet Technique"
Massimo Massetti, MDa,*,
Eugenio Neri, MDa,
Dimitrios Buklas, MDa,
Gerard Babatasi, MDa,
Olivier Le Page, MDa,
Jean Louis Gerard, MD,
André Khayat, MDa
a Thoracic and Cardiovascular Surgery, University Hospital, Caen, France
Accepted for publication December 29, 2003.
* Address reprint requests to Dr Massetti, Department of Thoracic and Cardiovascular Surgery, University Hospital, 14033 Caen Cedex, France
massetti-m{at}chu-caen.fr
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Abstract
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Valve-preserving aortic replacement has become an accepted therapeutic option for aortic dilatation with normal valve leaflets. The presence of a leaflet prolapse often induces the choice of a composite graft repair. In these cases, however, the repair of a leaflet prolapse is possible and represents a valuable alternative to a prosthetic valve. The conventional techniques of repair of a cusp prolapse are designed to restore coaptation through a reduction of free margin length. The sliding leaflet technique is an alternative procedure conceived to repair the prolapsed valve cusp by remodeling both the free margin and the annular insertion.
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Introduction
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Isolated aortic regurgitation in patients who have a morphologically normal valve leaflet is with increasing frequency treated with valve-preserving techniques [1]. Although the correction of leaflet prolapse has recently been proposed in association with valve-sparing aortic root replacement [2], the presence of an isolated prolapse of a single leaflet often induces the choice of a composite graft repair.
We present a new technique that, in presence of a dilated aortic root and a tricuspid aortic valve, restores valve coaptation and recreates the correct geometry of an isolated prolapsing cusp. This "sliding leaflet technique" is particularly indicated if the leaflet prolapse can be ascribed to an excess of length, affecting both the free margin and annular insertion of the leaflet.
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Technique
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Transesophageal echocardiography is routinely employed to intraoperatively analyze aortic valve anatomy and function. The heart is approached through a median sternotomy or ministernotomy [3]. Normothermic cardiopulmonary bypass is established between the right atrium and the distal ascending aorta. The aorta is cross-clamped, and a left ventricular vent is inserted thought the superior right pulmonary vein. A transverse aortotomy is then performed, and cold blood cardioplegia is administered selectively into the coronary ostia. Myocardial temperature is kept around 10°C as assessed by a myocardial temperature probe.
The first step of a repair technique is the assessment of valve geometry and leaflet morphology. The aortic wall is then entirely resected, including the sinus wall, and the aortic valve is mobilized by a careful dissection that is extended caudally to the level of the annulus. The commissures are suspended, using 5-0 Prolene (Ethicon, Somerville, NJ) sutures; another suture (6-0 Prolene) is passed in the free margin of the prolapsing cusp, through the noduli of Arantius, to put tension in the valve apparatus. The leaflet prolapse is thus evaluated, the tissue surplus is localized, and the optimal geometry assayed (Fig 1).
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Fig 1. A three-dimensional reconstruction of the aortic root with a prolapsed leaflet of the noncoronary cusp. The arrow shows the noncoronary leaflet prolapse.
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The next step entails the isolation of the prolapsed leaflet from the other two: two vertical incisions, at the level of the commissures, are carried from the sinotubular junction to the base of the intercommissural triangle (Fig 2); the cut involves the entire wall thickness. Care must be taken to avoid any injury to the leaflet tissue and to not damage the conduction tissue.
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Fig 2. Isolation of the prolapsed cusp: the vertical lines show the incisions carried out to separate the prolapsed cusp between the sinotubular junction and the base of the intercommissural triangles.
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When the prolapsing leaflet is completely mobilized, it is pulled cranially to restore cusp geometry and coaptation (Figs 3 and 4). This maneuver enables the identification of the level where commissural reattachment should begin (which is slightly cranial compared with the others). The two commissures are then reattached to each other with interrupted 5-0 Prolene sliding sutures. Commissural sliding restores the symmetry of the leaflet annulus: the elongated free edge is reduced by folding the parietal attachment of the cusp and fixing this ply to the aortic wall.
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Fig 3. The prolapsed cusp is lifted to the level of the two others by using a sliding suture technique.
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Fig 4. The reconstructed aortic root with the corrected cusp prolapse. The arrow shows the distance, at the commissures, between the originary position of the prolapsed leaflet (inferior line) and the leaflet after the sliding technique (superior line).
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The procedure is completed by valve reimplantation with a standard David technique [1]. After the root replacement, the graft is filled with saline solution to assess leaflet coaptation and valve continence. The coronary ostia are anastomosed with the button technique. After cardiopulmonary bypass is discontinued, systolic flow gradients are recorded and transesophageal echocardiography is used to assess the adequacy of the aortic valve repair.
Since June 2002, this technique has been used in 2 patients without the characteristics of Marfan syndrome. Both had severe aortic incompetence that was attributable to associated aortic root enlargement and leaflet prolapse, with asymmetric regurgitation jets. The first patient was a 49-year-old man who presented with a prolapse of the noncoronary cusp. His ascending aorta maximal diameter was 52 mm, and the sinotubular junction was 37 mm. The aortoventricular junction was 31 mm; therefore, a 32-mm graft was used. The second patient was 56 years old and had a prolapse of the right coronary leaflet. The maximal aortic, sinotubular, and aortoventricular junction diameters were 58 mm, 55 mm, and 30 mm, respectively. A 30-mm graft was used to replace the ascending aorta. The repairs were performed with cross-clamp times of 130 and 156 minutes, respectively. Immediate results were optimal in both patients, with no hospital complications. In one patient, echocardiography evidenced a central trivial incontinence. At follow-up, the repairs were stable at 18 and 9 months, respectively.
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Comment
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The morphologic characteristics and the function of the aortic valve are interrelated to the aortic root that connects the left ventricle with the ascending aorta [4, 5]. This complex structure has four anatomic components: the aortoventricular junction (or aortic annulus), leaflets, sinuses of Valsalva, and sinotubular junction. The aortic root is attached to contractile as well as fibrous components of the left ventricle. During systole, the interventricular septum shortens and moves inward, and the anterior leaflet of the mitral valve is pushed away from the center of the left ventricular outflow tract [4]. This places the area of the aortic root that is attached to the anterior leaflet of the mitral valve under greater tension than the area attached to the muscular interventricular septum during systole.
These dynamic changes in the geometry of the aortic annulus play a role in the function of the aortic valve. Anatomic abnormalities of each of the components of the aortic root may determine aortic insufficiency. Dilatation of the sinotubular junction causes outward displacement of the commissures of the aortic leaflets and prevents central coaptation, resulting in regurgitation. The aortic annulus may also dilate, contributing to the mechanism of insufficiency [6]. Although all three aortic leaflets open synchronously during systole, the noncoronary leaflet, and its annulus and commissures are exposed to a greater stress [6]. This may explain why the noncoronary aortic sinus and its annulus have the tendency to dilate more than the other sinuses in patients with degenerative disease of the aortic root [7]. A sagging cusp is commonly related to elongation of both the free edge and annular insertion of the leaflet.
Leaflet prolapse was originally treated by plicating the commissural end of the elongated free edge to the aortic wall, as popularized by Trusler and colleagues [8]. Recently, correction of leaflet prolapse has become an option in isolated aortic regurgitation, and its use has been introduced also in association with valve-preserving aortic root replacement. Langer and colleagues [2] reported the good results of the surgical correction of leaflet prolapse in combination with proximal aortic replacement. Midterm results were identical to those known with morphologically normal leaflets. Other surgical techniques used to correct leaflet prolapse include the plication of the commissural end of the elongated free edge to the aortic wall, or a triangular resection [9, 10]. These techniques entail the correction of the leaflet, while its annular insertion is untouched.
The triangular resection or plication that Carpentier [11] described aims to restore the normal length of the free edge. If the leaflet is thickened, a triangular resection is preceded by approximation of margins with interrupted sutures. If the leaflet is thin, a triangular plication is preferred to the prior method. Minor elongation of the free margin of a leaflet can also be corrected with a double layer of 6-0 Gore-Tex (WL Gore & Assoc, Flagstaff, AZ) expanded polytetrafluoroethylene suture passed along the free margin from commissure to commissure [9]. This technique allows a fine band of fibrous tissue to grow along the suture and surrounding leaflet tissue, reinforcing its free margin.
The sliding leaflet technique finds its rationale in the repair of the whole leaflet structure and corrects both the free edge and annular insertion components of the leaflet. It restores a physiologic geometry of the cusp and a symmetrical coaptation of the valve. In the light of the growing evidence of the durability of aortic valve repair, the option of preserving the physiologic aortic valve function appears more advantageous than prosthetic replacement. Although immediate and mid-term results are satisfactory, further experience and longer follow-up are nonetheless warranted to evaluate the durability of this technique.
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Acknowledgments
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We gratefully acknowledge the contribution of Arnaud Lacroix from Genzyme Biosurgery for the help in the preparation of the illustrations.
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References
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- David TE, Armstrong S, Ivanov J, Feindel CM, Omran A, Webb G. Results of aortic valvesparing operation. J Thorac Cardiovasc Surg. 2001;122:39–46[Abstract/Free Full Text]
- Langer F, Graeter T, Nikoloudakis N, Aicher D, Wendler O, Shäfers HJ. Valve-preserving aortic replacement: does the additional repair of leaflet prolapse adversely affect the results. J Thorac Cardiovasc Surg. 2001;122:270–277[Abstract/Free Full Text]
- Massetti M, Babatasi G, Lotti A, Bhoyroo S, Le Page O, Khayat A. Less invasive cardiac operation through a median sternotomy: 100 consecutive cases. Ann Thorac Surg. 1998;66:1050–1054[Abstract/Free Full Text]
- Dagum P, Green GR, Nistal FJ, et al. Deformational dynamics of the aortic root: modes and physiologic determinants. Circulation. 1999;100(19 Suppl):II54–II62
- Brewer RJ, Deck JD, Capat ID, Nolan SP. The dynamic aortic root: its role in aortic valve function. J Thorac Cardiovasc Surg. 1976;72:413–417[Abstract]
- Kunzelman KS, Grande J, David TE, Cochran RP, Verrier ED. Aortic root and valve relationship. J Thorac Cardiovasc Surg. 1994;107:162–170[Abstract/Free Full Text]
- Frater RWM. The prolapsing aortic cusp: experimental and clinical observations. Ann Thorac Surg. 1967;3:63[Medline]
- Trusler GA, Moses CAF, Kid BSL. Repair of ventricular septal defect with aortic insufficiency. J Thorac Cardiovasc Surg. 1973;66:394–403[Medline]
- Duran CG, Kumar N, Gometza B, Al Halees Z. Indications and limitations of aortic valve reconstruction. Ann Thorac Surg. 1991;52:447–454[Abstract]
- Haydar HS, He GW, Hovaguimian H, McIrvin DM, King DH, Starr A. Valve repair for aortic insufficiency: surgical classification and techniques. Eur J Cardiothorac Surg. 1997;11:258–265[Abstract]
- Carpentier A. Cardiac valve surgery: the "French correction". J Thorac Cardiovasc Surg. 1983;86:323–327[Medline]
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Abstract
Introduction
