Valve-Sparing Root Reconstruction

The heart is approached through a standard median sternotomy incision with cannulation of either the right axillary artery or the mid arch. The aorta is cross-clamped immediately below the innominate artery. If there is little aortic regurgitation, the first dose of cardioplegia may be delivered antegrade, with subsequent doses retrograde. If there is aortic insufficiency, I initiate cardioplegia retrograde, but after opening the aorta, deliver an initial dose antegrade directly down the coronary arteries with hand-held cannulae.

The aorta is transected and debrided down to the level of the sinotubular junction. Before disrupting the sinotubular junction to excise the coronary buttons, I prefer to use a universal sizer to estimate the optimal target sinotubular diameter. This will depend, in part, on the appearance of the free edges of the leaflets themselves and competence of the valve preoperatively. If the valve is quite competent, I will want to re-create the same diameter at the end of the procedure. If there is central regurgitation with normal looking leaflets, I will want to downsize a bit. If the free edges of the aortic leaflets are somewhat elongated, I will tend to make this diameter a bit larger. I find it easier to estimate this optimal diameter before excising the sinus tissue.

I place pledgeted mattress sutures above all three commissural posts and suspend the valve with traction on them. Coronary buttons are then excised in the usual manner. As each button is excised, I place a suture at the 12 o’clock position to maintain appropriate orientation of the button for ultimate implantation.

The excess sinus tissue is then resected down close to the level of the surgical annulus. I like to leave 2 to 3 mm of aortic wall tissue above the annulus to facilitate the second suture line. Simultaneous with resection of this tissue, I dissect outside of the aorta down to the level of the aortoventricular junction. This can usually be done with electrocautery on a low setting. By looking alternately inside and out, one can judge how deep into the root one must dissect to permit the subvalvular sutures to pass comfortably.

Horizontal mattress sutures of 3-O braided polyester suture are then passed through the aortoventricular junction several millimeters below the surgical annulus taking particular care to be well below the base of the leaflet at its nadir. Sutures can then be passed through the Dacron graft. This usually requires five sutures in each sinus.

I prefer to use a large-diameter graft for this portion of the reconstruction. An oversized graft here augments the effect of creating sinuses of Valsalva. In addition it greatly facilitates the second, subcoronary anastomosis. I prefer to size the native annulus with a universal sizer and then upsize my graft by 5 or 6 mm. This decision is also informed by my target final desired sinotubular diameter determined as described above. Again I want to use a graft that will exceed that final sinotubular diameter so that by reducing to the desired dimensions, a neosinotubular junction and sinuses of Valsalva will be created.

The graft is then seated around the valve and the commissural posts resuspended at an appropriate height. Setting the sinuses high in the graft augments the creation of adequate sinuses of Valsalva.

The subvalvular sutures are then gently tied taking care not to gather the annulus excessively. I personally have found it useful to place a universal sizer across the valve as I tie the sutures to prevent excessive gathering. It also assures me of a precisely measured annulus.

After tying the subvalvular sutures, the valve sizer is removed and the subcoronary anastomosis performed with running 4-O prolene. I prefer to initiate that anastomosis at the nadir of each sinus, passing my first suture as a horizontal mattress with the knot on the outside of the graft. I then pass the needle inside of the Dacron graft and sew each subcoronary suture line from aorta to graft such that the leaflets are protected and the natural pass of the needle will tend to gather graft with each stitch. This gathering is critical to creating adequate sinuses.

It is also important when constructing this suture line to keep this anastomosis low and horizontal at the base of the cusp and then climb quite vertically to the top of the commissural posts. One wants to leave as much Dacron in the belly of the neosinuses as possible and not gather Dacron up behind the commissure. Any Dacron that is included within the commissures lessens your neosinuses.

Coronary buttons are then reimplanted at an appropriate height in the usual manner with running 5-O prolene.

It is worth noting that in creating the openings for the coronary buttons one must be careful not to injure the leaflets. I often cut this opening from the inside out for just this reason.

I then create my neosinotubular junction using a second Dacron graft of an appropriate diameter to create my neosinotubular junction of the diameter determined at the beginning of the case. The graft-to-graft anastomosis tends to leak less with a strip of Teflon felt as a gasket.

The distal anastomosis is also facilitated by the use of a smaller Dacron graft as very frequently the distal ascending aorta is of relatively normal diameter.

The final product should create a relatively normal-appearing root with full sinuses of Valsalva.