International Society For Minimally Invasive Cardiothoracic Surgery

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Utilization Of Subannular Ring To Stabilize The Ventriculo-aortic Junction
Cinthia Orlov, Oleg Orlov, Vishal Shah, Vivian Tran, Sophia Strine, Serge Sicouri, Konstadinos Plestis.
Lankenau Medical Center, Wynnewood, PA, USA.

OBJECTIVE: Aortic circumferential external annuloplasty has been proposed as a durable option compared to subcomissural annuloplasty in stabilizing the ventriculo-aortic junction. Herein, we present a case of bicuspid aortic valve repair with free edge plication of both leaflets and subannular and sinotubular rings placement.
METHODS: A 65-year-old male presented with severe eccentric aortic valve regurgitation. The transesophageal echocardiography revealed a prolapse of the conjoint leaflet and an eccentric jet directed towards anterior leaflet of the mitral valve. An upper partial sternotomy with extension to the right third intercostal space was performed. The ascending aorta and the right common femoral vein were cannulated using the Seldinger technique under TEE guidance. The aorta was cross-clamped, and the heart was arrested with one dose of antegrade HTK-Custodiol cardioplegia. A transverse aortotomy was performed 1 cm above the sinotubular junction, and additional cardioplegia was given directly to the coronary artery ostia.
RESULTS: Following exposure of the aortic valve, three sutures were placed into the apex of each of the three commissures. The initial annular size was 27mm. A series of interrupted pledgeted sutures were placed underneath the aortic valve, sparing the areas of the right and left main coronary arteries. The sutures were passed through a ring that was tailored to accommodate the placement of the ring underneath the coronaries. The sutures were tied over a dilator to establish an aortoventricular junction of 23mm. Free edge plication of the left coronary, as well as the conjoined leaflets, were performed to establish an effective height of 10 mm. Next, the aortotomy was closed at the level of the sinotubular junction with 5-0 Prolene in a continuous fashion utilizing a 31 mm band to buttress the anastomosis. The chest was closed in a standard fashion. The patient had an uneventful postoperative course.
CONCLUSIONS: Minimally invasive aortic valve repair with external annular ring placement is a safe technique that prevents further annular dilation while preserving the aortic valve and sinuses.

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