FrederickGrover 2016 PARTIPRIMARYAORTICVAL MasterTechniquesInSur

Part I
Primary Aortic Valve Surgery

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1
Open Aortic Valve Replacement—Mechanical Versus Tissue
Prosthesis
A. P. Kappetein
INDICATIONS
Aortic Stenosis
Aortic valve stenosis is the most common valvular heart disease and the most frequent cardiovascular
disease after hypertension and coronary artery disease. Of all people over age 65 years, stenosis is
present in 2% to 7% of this population. With the growing elderly population, the prevalence of this
disease will continue to increase.
Aortic stenosis may be caused by: (1) senile calcification of a morphologically normal tricuspid valve,
(2) progressive calcification of a congenitally bicuspid valve, or (3) rheumatic fever which causes mixed
stenotic and regurgitant lesions and is commonly associated with mitral valve disease. AS is rarely
associated with systemic diseases such as Paget disease of bone and end-stage renal disease.
Degenerative calcification is an active process with similarities to atherosclerosis and is mediated by
inflammation, mechanical stress, and lipid deposition with macrophage infiltration. Atherosclerotic
coronary artery disease is present in nearly 50% of patients with calcific aortic stenosis. Stenotic,
bicuspid valves present primarily in the fourth and fifth decade of life, while calcified tricuspid valves
usually present later in the seventh to ninth decade.
The normal human aortic valve area (AVA) is between 3 and 4 cm2 with minimal to no gradient.
Acquired aortic stenosis is characterized by gradual calcification of the cusps and increasing reduction
of the orifice cross-sectional area. Cardiac output is from the start maintained through left ventricular
(LV) hypertrophy and increase of the gradient across the valve. LV hypertrophy acts as a compensatory
mechanism to restore wall stress and preserve cardiac output under increasing pressure afterload caused
by the stenotic valve. During this stage, LV diastolic filling and LV longitudinal shortening are already
decreased. When the stenosis restricts the increase in cardiac output during physical activity, dyspnea,
hypotension, angina and syncope may occur. Continuing cardiomyocyte death and replacement with
fibrosis and LV hypertrophy leads to development of LV dysfunction and heart failure (HF) symptoms.
Patients with aortic stenosis remain asymptomatic for several years but development of symptoms
signals an inflection point in the survival and mortality rate is around 50% after 3 years. In
asymptomatic patients with a severe aortic stenosis, sudden cardiac death is around 1.5% per year.
Differentiating between asymptomatic and mildly symptomatic patients is often challenging, although
symptom onset is a key factor in the indication for intervention. Predictors of symptom development in
asymptomatic patients are older age, rate of hemodynamic progression, peripheral vascular disease,
increase in gradient with exercise, excessive LV hypertrophy, and symptoms occurring during exercise
testing. The onset of symptoms is not the only indication for intervention. A reduced LV function
ejection fraction of less than 50% is also a class I (level of evidence B) indication for aortic valve
replacement.
TABLE 1.1 Stages of Valvular Aortic Stenosis
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Aortic stenosis is defined as mild, moderate, and severe, and the corresponding AVA, mean gradients,
and peak jet velocities are shown in Table 1.1. In the presence of normal cardiac output, the
transvalvular gradient is typically greater than 50 mm Hg when the AVA is less than 1 cm 2. A rapid
increase in transvalvular gradient is seen when the AVA is less than 0.8 to 1.0 cm2.
Despite the absence of data from a randomized clinical trial, symptomatic severe aortic stenosis is
considered a class 1 indication for surgery.
The average AVA is 0.6 to 0.8 cm2 at the onset of symptoms. Gradual progression of outflow
obstruction and ventricular hypertrophy leads to symptoms of aortic stenosis, which are: (1) angina, (2)
syncope, and (3) dyspnea or congestive HF. Various studies have demonstrated that average life
expectancy in patients with hemodynamically significant aortic stenosis is 4 years with angina, 3 years
with syncope, and 2 years with congestive HF.
Aortic Regurgitation
Patients with infective endocarditis and aortic dissection may suffer from acute severe aortic
regurgitation and without intervention their prognosis is bad. In patients with chronic severe aortic
regurgitation the most common causes are calcific valve disease and bicuspid aortic valve. Aortic
regurgitation may also be associated with dilatation of the ascending aorta or sinuses of Valsalva. The
disease course is over a longer time and LV volume overload increases slowly with LV dilatation.
Symptoms of HF develop over time and are linked with a poor long-term prognosis. Patients with mild
to moderate aortic regurgitation are generally asymptomatic and the likelihood of adverse events is low.
Patients with chronic aortic regurgitation should be monitored with clinical assessment and
echocardiography, for alterations in symptoms, severity of aortic regurgitation, and LV systolic
dysfunction. Aortic valve replacement improves survival, reduces symptoms, prevents development of
HF, and avoids aortic complications in patients with dilatation of the ascending aorta. AVR is indicated
for symptomatic patients with severe regurgitation regardless of LV systolic function or in
asymptomatic patients with chronic severe regurgitation and LV systolic dysfunction.
PREOPERATIVE PLANNING
The Choice of Prosthesis
Prosthetic valves are generally grouped as mechanical or biologic. Many prosthetic valves have been
developed over the years with the aim of improving hemodynamic function, increasing durability, and
reducing complications. Nevertheless, there is no perfect valve, and all prosthetic valves carry
complications.
Mechanical Prosthesis
The most commonly implanted mechanical valves are the bileaflet valves. The major benefit of
mechanical prosthesis is their durability. However, their Achilles heel is the need for lifelong
anticoagulation, frequent INR tests, difficulties in starting interaction with other drugs, maintaining an
adequate level of anticoagulation, and high chances of bleeding. The risk of a bleeding complication
from anticoagulation is between 1% and 2% per year. Anticoagulation risk is higher in aging patients
and in patients with comorbidities like congestive HF, hypertension, diabetes mellitus, and stroke or
transient ischemic attack. The closure clicks of mechanical heart valve prostheses’ leaflets are quite
often audible. However, only a small minority (6%) of mechanical heart valve recipients complain about
the valve noise.
Biologic Prosthesis
The most frequently implanted biologic valve is a stented xenograft. The leaflets of stented pericardial
xenografts are made from bovine or porcine pericardium. Biologic valves are at risk for structural valve
deterioration. The age of the patient at the time of implant is the most critical risk factor, the younger the
patients, the faster the valve deterioration. Life expectancy is therefore an essential aspect of valve
selection taking into account that in patients with a prosthetic heart valve, life expectancy is reduced
compared to the general population.
Patients older than 65 years usually do not outlive the life expectancy of a tissue valve and implanting
a bioprosthesis precludes anticoagulation. For patients younger than 60 to 65 years undergoing aortic
valve replacement, a bileaflet mechanical valve seems to be the best choice. However, there is an
increase in the use of bioprosthetic heart valves also in patients aged 60 years or younger because of an
improved quality of life without warfarin and without the clear noise of the mechanical prosthesis. The
durability of tissue valves with low rates of structural valve deterioration, improved surgical techniques
and postoperative care have diminished the risk of a redo aortic valve replacement procedure. The
outlook of a valve-in-valve procedure with a transcatheter aortic valve may also influence the age at
which a bioprosthetic valve is recommended. Patients with bioprostheses will also need anticoagulation
if they develop atrial fibrillation. However, for atrial fibrillation one can keep the international
normalized ratio at a lower level compared to a mechanical prosthesis.
If valve replacement is necessary in women of childbearing age, the choice of the type of prosthetic
valve is difficult. Mechanical valves mean that anticoagulation with warfarin, phenprocoumon or
acenocoumarol is needed with an increased risk of fetal loss or malformation and an increased risk of
maternal prosthetic valve thrombosis and peripartum bleeding.
Patient choice also plays a role in the selection of a bio- or mechanical- prosthesis. If the patient is
medically noncompliant, the level of anticoagulation cannot be closely checked, or he or she rejects to
be on anticoagulation therapy a bioprosthesis might be a better choice and the choice of a mechanical
valve not appropriate. On the other hand, if the patient is opposed to reoperation a mechanical valve
type is more suitable.
The following recommendations for choosing a prosthesis are according to the 2014 American Heart
Association/American College of Cardiology valve guideline:
A mechanical prosthesis is suggested for surgical aortic valve replacement for patients <60 of
age who do not have a contraindication to anticoagulation.
A bioprosthetic valve is suggested for patients >70 years old (and for those with life expectancy
lower than the expected durability of the bioprosthesis).
Either a bioprosthetic or mechanical valve is suggested in patients between 60 to 70 years of
age.
A bioprosthetic valve is recommended in patients of any age for whom anticoagulant therapy is
contraindicated, cannot be managed appropriately, or is not desired.
For young patients for whom anticoagulation is contraindicated or undesirable (e.g., those with
possible future pregnancy), replacement of the aortic valve by a pulmonary autograft (Ross
procedure) by an experienced surgeon is a potential option.
SURGERY
After induction of general anesthesia, the patient is positioned supine. A transesophageal
echocardiographic probe is inserted to allow detailed intraoperative echocardiographic examination. The
patient is prepped and draped in standard sterile fashion.
Technique
The usual surgical technique for aortic valve replacement is via a median sternotomy. After opening the
pericardium, cardiopulmonary bypass is instituted with a cannula in the aorta and a two-stage atrial
venous cannula through the right atrial appendage. A LV vent is inserted via the right superior
pulmonary vein through the left atrium and trough the mitral valve into the left ventricle to maintain a
dry operative field. The plane between the aorta and pulmonary artery is dissected to improve
visualization of the aortic valve and to make aortic closure easier. The patient is cooled to a bladder
temperature of 32°C.
The aorta is cross-clamped and cardioplegia is administered.
Crystalloid or blood cardioplegia can be administered through a retrograde coronary sinus catheter or
through an antegrade cannula in the aortic root or, in case of aortic valve regurgitation, directly in the
coronary ostia using coronary perfusion cannulae. In the situation of aortic insufficiency and antegrade
administration of cardioplegic solution, this will result in backflow of the cardioplegia toward the LV
cavity and may cause LV dilation if LV drainage is inadequate.
Figure 1.1 Aortotomy through hockey-stick incision.
After cross-clamping of the aorta a transverse aortotomy is made approximately 1 cm above the
sinotubular junction. It is important to make the aortotomy not too close to the right coronary ostium to
avoid injury or distortion during aortic closure. The aorta is opened with a conventional hockey-stick
incision extending to the noncoronary sinus of Valsalva stopping 1 cm above the aortic annulus (Fig. 1.1
).
Better visualization of the aortic valve can be achieved by putting the operating table slightly in
reverse Trendelenburg position and marginally rotated to the patient’s left side.
Exposure of the aortic root is enhanced by traction stitches (4-0 polypropylene or silk sutures) that are
placed at the tip of each of the three commissures. The stitches are pulled up to provide better exposure
of the aortic annulus (Fig. 1.2).
The leaflets of the aortic valve are removed with scissors, starting at the commissure between the
right and noncoronary sinus. The valve cusps are excised with removing as much of the calcification as
possible (Fig. 1.3). Remaining calcium is detached using a Rongeur instrument while the assistant
follows with the suction catheter capturing small pieces of calcium. Calcifications often extend onto the
anterior mitral leaflet and as much calcium is removed as needed to guarantee proper placement of the
valve prosthesis. Injuring the anterior mitral leaflet should be avoided.
Figure 1.2 Calcified aortic valve with stay sutures in commissures.
Figure 1.3 The valve cusps are excised with removing as much of the calcium as possible.
A surgical sponge can be put into the cavity of the left ventricle during decalcification to capture
debris. After decalcification, the LV vent is stopped, the sponge removed, and the left ventricle flooded
with cold saline under aspiration with the high-pressure sucker to capture debris. The LV vent is again
turned on. The area of the aorta near the cross-clamp is inspected for loose calcific fragments. Special
precautions may also be taken to prevent calcium emboli falling into the left coronary ostium.
The annulus is calibrated, with a sizer that matches to the specific prosthesis (Fig. 1.4). A properly
sized valve is chosen not attempting to place a valve that is too large. If the aortic annulus is too small to
accommodate a valve with a satisfactory hemodynamic performance, the aortic annulus should be
enlarged (see section on annular enlargement).
The valve is sewn to the aortic annulus with either pledgeted sutures or nonpledgeted double needle
2-0 Ti-Cron sutures (Fig. 1.5). Pledgeted suture are only beneficial when the annulus is friable. In case
pledgeted sutures are needed they are placed in a horizontal mattress fashion, taking deep bites, with the
pledgets in the subannular position, placing the sutures from the ventricular side of the annulus to the
aortic side of the annulus. In case of a mechanical prosthesis, the pledgets should not interfere with
movement of the discs. If a suture breaks during tying, be sure to remove the loose pledget.
Nonpledgeted sutures can either be placed in a horizontal mattress fashion or as simple interrupted
sutures. Sutures with two different colors are used to simplify identification of suture pairs. Suturing is
initiated at the commissure between the left and right coronary cusps. Stitches are placed in the right
coronary in a clockwise fashion and in the left coronary annulus in the anticlockwise fashion. In the
noncoronary annulus stitches are placed in a clockwise fashion while the needles are passed through the
annulus in backhand fashion. Sutures should not be placed too deep near the right and noncoronary
annuli as they can injure the conduction tissue which may result in various forms of heart block.
Figure 1.4 The annulus is calibrated, with a sizer that corresponds to the specific prosthesis.
Figure 1.5 The valve is sewn to the aortic annulus with either pledgeted sutures (below [c] or above [d] the annulus)
or nonpledgeted double needle 2-0 Ti-Cron sutures (a+d).
Once all the valve sutures have been placed, the sutures are passed through the valve sewing ring (
Fig. 1.6). Alternatively, each suture can be passed through the annulus and the sewing ring of the valve
in one step. The three groups of sutures are bundled and clamped by a hemostat, the needles are
removed. The sutures are retracted and the prosthesis can slide over the sutures toward the supra-annular
position (Fig. 1.7). The valve holder can now be disconnected. All sutures are tied with the sutures of
the noncoronary cusp fixed last. Sutures should be cut immediately above the knots, if the sutures are
too long they overhang into the valve orifice and will interfere with disc movement and the valve may
be hindered.
Figure 1.6 The valve sutures have been placed and the sutures are passed through the valve sewing ring.
Figure 1.7 The prosthesis slides over the sutures toward the supra-annular position.
Before closing the aorta, leaflet motion of the prosthesis should be tested and unobstructed access to
the coronary ostia assessed.
The aortotomy is closed with 4-0 polypropylene suture in two layers. The first suture is a running
horizontal mattress suture while the second suture line is an over-and-over running stitch. The first stitch
is begun at the posterior rightward angle and continued to the midportion. The other is started at the
anterior leftward angle and carried out to the midpoint where it is tied to the first stitch.
When the struts of the tissue prosthesis protrude into the aortotomy this may result in tension along
the suture line. In that case a patch enlargement of the aortotomy can be performed using a pericardial
patch or a Dacron patch (Fig. 1.8).
After closing the aorta, strong suction is placed on the cardioplegia cannula in the aortic root for
de-airing, suction on the ventricular vent is decreased while the aortic cross-clamp is released. With the
heart beating, the presence of air is evaluated and confined by transesophageal echocardiography.
Figure 1.8 Patch enlargement of the aortotomy when strut is protruding.
Figure 1.9 Incision in the center of the anterior mitral valve leaflet.
In case of bradycardia or AV block, temporary pacemaker wires are placed on the right atrium and
right ventricle to allow for atrioventricular sequential pacing.
Annular Enlargement
The goal of aortic valve replacement is to reduce the gradient across the aortic valve as much as
possible. A high residual transvalvular gradient may impair LV remodeling and numerous studies have
linked prosthesis–patient mismatch after aortic valve replacement to adverse outcomes. Performing an
aortic root enlargement to accommodate a larger prosthesis size may therefore be considered if the
risk–benefit ratio is acceptable. Usually the patch will enlarge the root by one valve size. To carry out
the so-called “Nick” procedure, the aortotomy incision is extended through the noncoronary sinus,
across the annulus as far as to the origin of the anterior mitral valve leaflet (Fig. 1.9). The aortic annulus
opens up in the form of an inverted V with the apex toward the anterior mitral valve leaflet. Beginning
at the apex of the incision a tongue of Dacron or glutaraldehyde-treated autologous pericardial patch is
sutured in place with a continuous 3-0 Prolene suture (Fig. 1.10). When further enlargement is needed
the incision can be extended into the anterior mitral leaflet. The roof of the left atrial wall is hereby also
incised. Again a patch is used to close the defect. Suturing the pericardial patch should incorporate the
left anterior mitral valve leaflet and the roof of the left atrium. The valve sutures are then placed using
pledgets through the pericardial patch from outside to the inside (Fig. 1.11). Special care is needed to
inspect possible bleeding sites before releasing the aortic cross-clamp as it is difficult see this area again.
The aortotomy is closed with or without using part of the patch.
Figure 1.10 A patch is sewn into the defect in the anterior leaflet.
Figure 1.11 Valve sutures through the pericardial patch from outside to inside.
POSTOPERATIVE MANAGEMENT
On the second postoperative day the chest tubes are removed if output is less than 125 mL in the
previous 8 hours.
Patients with a bileaflet mechanical prosthesis and no additional risk factors need to be anticoagulated
with vitamin K antagonists to achieve a goal INR of 2.5. In case additional risk factors are present (atrial
fibrillation, prior thromboembolism, LV dysfunction, or a hypercoagulable state) the goal INR is 3.0.
The European Society of Cardiology (ESC)/European Association for Cardio-thoracic Surgery
guidelines suggest to additionally add low-dose aspirin in patients with a mechanical prosthesis and
concomitant atherosclerotic disease and in those patients who had a thromboembolic event despite
adequate INR. The American College of Cardiology/American Heart Association (ACC/AHA)
guidelines recommend the addition of aspirin therapy in all patients with a mechanical prosthesis. High
variability of the INR is a strong independent predictor of complications leading to reduced survival
after valve replacement. Self-management of anticoagulation can reduce INR variability and clinical
events, although appropriate training is required.
For patients with a bioprosthesis the recommendation is low-dose aspirin for the first 3 months after
implantation. Although anticoagulation, with a vitamin K antagonist to achieve an INR of 2.5 may be
reasonable for the first 3 months after bioprosthetic AVR.
COMPLICATIONS
Thromboembolic Complications
Thromboembolic complications are a major cause of morbidity and mortality in patients with a
prosthetic heart valve, with a projected event rate between 0.6% and 2.3% per patient-year.
In addition, in patients on chronic anticoagulation the annual chance of a hemorrhagic event is around
1–2% per patient-year.
Valve Thrombosis
Thrombosis of mechanical valves can follow inadequate anticoagulation therapy and results in
functional stenosis or regurgitation. A valve thrombosis can develop slowly or may have an acute onset.
In patients who are hemodynamically stable the first step is intravenous anticoagulation. However, in
case of hemodynamic instability often a reoperation is necessary whereby the valve needs to be
replaced.
Pannus Formation
Pannus formation involves fibrous tissue ingrowth covering the circumference of a prosthetic valve, and
affecting valve function. The incidence is very low and usually occurs only with mechanical prosthesis.
Patient–Prosthesis Mismatch
Patient–prosthesis mismatch arises when the functional area of the prosthetic valve is too small for the
cardiac output. Prosthesis–patient mismatch might not affect survival in most patients, but is a
determinant of prognosis in patients with impaired ventricular function. Severe patient–prosthesis
mismatch leads to a higher hospital mortality.
Structural Failure
Structural failure of a mechanical heart valve is rare and when it occurs it is due to thrombus formation,
tissue overgrowth (pannus), or paravalvular regurgitation due to infection. Structural failure of
bioprosthetic heart valves is more common and due to calcification and tissue degeneration but
decreases with increasing age of the patient.
Infective Endocarditis
The risk of prosthetic valve endocarditis is 0.5% per year. The highest incidence is within the first
month after the operation and frequently related to an infection with Staphylococcus epidermidis. Late
endocarditis has a microbial spectrum similar to that seen in native valve endocarditis. Often the sewing
ring is involved with paravalvular abscess formation and paravalvular regurgitation.
Paravalvular Leakage
Most paravalvular leaks that are detected during or immediately after surgery are trivial or mild and do
not progress during follow-up. New, severe paravalvular leaks that occur during follow-up are usually
associated with endocarditis or structural failure.
Hemolytic Anemia
Hemolysis is usually mild and more often seen with mechanical prosthesis. It is associated with
paravalvular leakage leading to rapid acceleration and deceleration of the regurgitant jet and/or high
peak shear rates. Reoperation or percutaneous closure of the paravalvular leak with an Amplatzer septal
occluder, duct occluder, muscular ventricular septal defect occluder, or vascular plug, is indicated in
cases of severe hemolysis with anemia or HF.
RESULTS
The in-hospital mortality rates after aortic valve replacement for aortic valve stenosis is 1% to 3% in
patients younger than 70 years and 4% to 8% in older patients. Risk factors for operative mortality are
older age, peripheral vascular disease, cerebrovascular accident, pulmonary hypertension, LV
dysfunction, coexisting coronary artery disease, and previous bypass or valve surgery. Usually after a
successful aortic valve replacement quality of life and life expectancy are improved.
Valve-related morbidities include prosthetic valve endocarditis, thromboembolism, reoperation, and
bleeding.
All patients with mechanical valves need lifelong anticoagulation although there is the risk of
bleeding complications.
CONCLUSIONS
Surgical operative valve replacement can be performed with low hospital mortality and excellent
long-term outcome. With increasing durability of bioprosthetic heart valves, the choice is often made for
this type of valve to avoid anticoagulation that is needed with mechanical valves. In the future, however,
more patients, especially those at older age and at higher risk for surgery may benefit from a less
invasive approach by implantation of transcatheter heart valve and the number of surgical aortic valve
replacements may decline (see Chapter 2).
Recommended References and Readings

Cremer PC, Rodriguez LL, Griffin BP, et al. Early Bioprosthetic Valve Failure: A Pictorial Review of Rare Causes. JACC
Cardiovasc Imaging. 2015;8(6):737–740.
Head SJ, Mokhles MM, Osnabrugge RL, et al. The impact of prosthesis-patient mismatch on long-term survival after aortic
valve replacement: A systematic review and meta-analysis of 34 observational studies comprising 27 186 patients with 133
141 patient-years. Eur Heart J. 2012;33(12):1518–1529.
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart
disease: Executive summary: A report of the American college of cardiology/American heart association task force on practice
guidelines. J Am Coll Cardiol. 2014;63(22):2438–2488.
Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): The Joint
Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European
Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg. 2012;42(4):S1–S44.
2
Transcatheter Aortic Valve Replacement
Eric L. Sarin and Vinod H. Thourani
Introduction
Surgery to replace a dysfunctional aortic valve remains the most common indication for valvular heart
surgery. The increased incidence of degenerative aortic valve disease among the elderly coupled with
increasing life expectancies across the Western world has resulted in a growing number of older patients
with clinically significant aortic valve disease. As a result, surgeons are seeing older patients, with more
comorbidities, who are at an increased risk for perioperative morbidity and mortality.
In the past, a significant subset of these patients was not referred for surgical evaluation because of
their perceived risk of complications. The rise of transcatheter aortic valve replacement (TAVR) over
the last decade has offered promise as a durable therapeutic option for those patients previously
considered to be at increased risk or unsuitable for surgical valve replacement with cardiopulmonary
bypass (SAVR).
INDICATIONS/CONTRAINDICATIONS
The indications for TAVR in those with aortic stenosis (AS) are similar to those for surgical aortic valve
replacement. Symptomatic patients with severe aortic stenosis, defined as a peak aortic jet velocity (V
2
max) 4 m/s, aortic valve area (AVA) <1 cm , or mean aortic valve gradient 40 mm Hg, can be
considered for TAVR. Currently in the United States, TAVR is commercially approved for patients with
greater than 1-year life expectancy and symptomatic, severe AS who are considered to be either at
high-risk for perioperative complications or inoperable. This decision should be made by a
multidisciplinary Heart Team representing specialists in cardiac surgery, interventional cardiology,
echocardiography, and cardiac anesthesia. High-risk patients are defined by a Society of Thoracic
Surgeons’ (STS’) predicted risk score of 8% or by comorbid conditions that are associated with a
predicted risk of perioperative death 15%.
Patient selection is of paramount importance when planning a TAVR. In addition to the standard
preoperative evaluation for comorbid disease, a thorough TAVR-specific pre-op evaluation should
address the following:
Severity of aortic stenosis, including the anatomic details of the valve leaflets (leaflet height,
bicuspid vs. tricuspid)
Peripheral vascular disease: ileofemoral vessel size, calcification, and tortuosity, and prior
surgical procedures (iliac stenting, aortoiliac reconstruction)
Annular, sinotubular, and sinus of Valsalva dimensions
Ventricular function and concomitant valvular pathology (e.g., severe mitral or tricuspid
regurgitation)
Presence of concomitant coronary artery disease
Typically, a combination of imaging techniques is used to answer these questions. Our institution
routinely employs left heart catheterization; high-definition computed tomography (CT) of the chest,
abdomen, and pelvis; and transthoracic echocardiography (TTE) or transesophageal echocardiography
(TEE). Furthermore, objective frailty testing, pulmonary function tests (PFTs), and carotid duplex
ultrasound are performed to assess lung function and carotid stenosis. Hemodynamically significant and
symptomatic carotid lesions should be treated prior to TAVR.
Aortic Valve Assessment

All patients should have a CT scan from the aortic valve to the femoral bifurcation. A gated, contrast CT
with 3-D reconstruction provides detailed information regarding the aortic root anatomy, particularly
dimensions of the aortic annulus, sinotubular junction, and sinuses of Valsalva. Also of considerable
importance are the heights of the coronary ostia above the annular plane. Measurement of the annular
area or perimeter has largely supplanted two-dimensional echocardiography and is considered the
standard of care for TAVR sizing. Each TAVR valve provides a sizing chart corresponding to the
annular area or perimeter.
A complete echocardiographic assessment, typically a TTE, is required for each patient and provides
complimentary information to the CT scan. From the parasternal long-axis view, the right and
noncoronary cusps are identified, and the annulus is measured between the insertion points of the
leaflets. Accurate measurement is essential as it will be used to choose the size of the bioprosthesis. If
calcification, body habitus, or other factors preclude the accurate measurement of the annulus, a TEE
should be performed.
Some patients may end up in-between valve sizes based on their CT scan and echocardiographic data.
In these instances, balloon sizing of the annulus with supravalvular aortography during balloon aortic
valvuloplasty (BAV) may provide additional information to guide prosthesis sizing. The surgeon must
bear in mind that based on BAV sizing, if a larger valve is chosen this may increase the delivery sheath
size. In this instance, a thorough knowledge of the ileofemoral vessel dimensions is critical.
Lower Extremity Assessment

Assessment of the lower extremities begins with either a CT scan or lower extremity angiography at the
time of cardiac catheterization. Particular attention must be paid to the vessel diameters of the
ileofemoral system bilaterally. Significant calcification of the ileofemoral system is not uncommon, but
does not necessarily preclude a femoral artery approach. However, in cases of severe calcification where
the involvement is circumferential and size-limiting, alternative access sites should be considered.
Tortuosity, particularly in the external iliac artery, may limit the safe advancement of the delivery
sheath. Even moderate calcification of a tortuous external iliac artery can increase the likelihood of
major vascular complications. Tortuous vessels that are free of significant calcification are often
compliant and can usually be straightened by a stiff guidewire. While previous surgical procedures
(aortoiliac replacement, iliac stenting) are not absolute contraindications to a femoral approach, they
need to be approached with caution. Synthetic graft material will not behave like native tissue and may
prove difficult to traverse with the necessary sheaths and guidewires. This should always be done under
direct fluoroscopic visualization with a low threshold for conversion to alternative access if significant
resistance is met.
Coronary Considerations
Patients with severe coronary artery disease and significant lesions that are amenable to percutaneous
coronary intervention (PCI) should undergo implantation utilizing a bare metal or drug-eluting stent
prior to TAVR, particularly if rapid pacing is planned during the procedure. The transient hemodynamic
instability often seen during TAVR deployment will be magnified in patients with an increased coronary
ischemic burden.
Another potential concern that may be raised during preoperative evaluation is the risk of acute
coronary obstruction following valve deployment. A narrow sinus of Valsalva (within 5 mm of the
annulus size), short coronary ostia height (<10 mm), and bulky leaflet calcification may all increase the
risk for coronary obstruction. These patients should have guidewires or an angioplasty balloon placed in
the affected coronary ostia prior to TAVR deployment to facilitate rapid stenting, if necessary.
Alternative Access Considerations

If the preoperative evaluation determines that TF-TAVR is not feasible, alternative access techniques
should be considered. The transapical (TA) approach, done via an anterior left mini-thoracotomy, was
the main alternative used in the PARTNER trials. In experienced hands this approach is very effective,
but may not be appropriate for all patients, particularly those with significant parenchymal lung disease
or low ejection fraction. The subclavian and transaortic (TAo) approaches were popularized by the
CoreValve trial and are gaining in popularity. Far less common approaches for those patients who are
not suitable for TA, TAo, or subclavian are the transcarotid and transcaval approaches.
SURGERY
Transfemoral TAVR
Transfemoral delivery is the least invasive TAVR approach and has become the procedure of choice in
patients with appropriate vasculature. A 6-Fr sheath is placed in the artery and vein on the nonimplant
side. A pigtail catheter is advanced to the aortic valve and aortography is performed to confirm the
correct valve plane for valve placement. Typically, this is performed with the pigtail catheter in the right
coronary cusp. The proper deployment angle is identified when all three cusps are aligned at an equal
height (Fig. 2.1).
Using the femoral vein, a temporary pacemaker is advanced to the right ventricular apex for purposes
of rapid ventricular pacing. The ability to provide consistent pacing capture is critical, particularly for
balloon-expandable TAVR deployment. In order to gain stability and facilitate adequate contact of the
pacemaker with the right ventricular myocardium, we utilize an 8-Fr Mullins sheath advanced into the
right atrium.
The femoral artery on the implant side can be accessed by direct surgical cutdown or percutaneously
depending on the surgeon’s preference. Percutaneous access to the femoral artery is performed utilizing
a microneedle under vascular road mapping to assure puncture of the anterior wall of the vessel. Once
wire access is confirmed, a 7-Fr sheath is inserted and removed to dilate the tract and the artery is
preclosed with two Perclose devices. Over an extra-stiff wire, the vessel is serially dilated to
accommodate the delivery sheath. The patient is heparinized to an ACT of >250 seconds. Excessive
force should not be applied when passing the dilators to avoid vascular complications during insertion
and removal.
Figure 2.1 Set-up depicting typical access for transfemoral TAVR with delivery and nondelivery sides. Insets depict
balloon-tipped pacing catheter in right ventricle and coplanar alignment of aortic cusps (“deployment angle”) with an
angled pigtail.
Next, the aortic valve is crossed using an Amplatz left-1 (AL1) catheter and a straight guidewire. This
is then exchanged for a 260-cm long, 0.035-inch Amplatz extra-stiff J-tipped wire with an exaggerated
pigtail bend at the proximal end. In those undergoing a self-expanding valve implantation, a super-stiff
J-tipped wire can be inserted in the left ventricle in lieu of the extra-stiff wire. BAV is performed under
rapid ventricular pacing (generally 180 to 220 beats/minute) with an appropriately sized balloon
catheter.
The appropriate valve delivery system is inserted and advanced to the aortic annulus. Difficulty in
crossing the aortic valve can occur as the stiff wire may bias to the greater aortic curvature and may
become lodged in a commissure. Gentle traction on the wire will center the delivery system and
facilitate crossing the valve. Once across the native valve, the system should not be advanced further to
avoid perforation of the left ventricular apex. Proper positioning of the valve is guided by fluoroscopy
and echocardiography.
The SAPIEN valve is ideally positioned so that its upper margin covers the aortic leaflet tips, while
the ventricular end covers the aortic annulus or below. The CoreValve’s position is determined by its
three-tiered design, with the inflow portion of the valve ideally placed 6 mm (one diamond segment of
the stent frame) below the point of leaflet attachment. This places the portion of the valve with the
highest radial force firmly in the annulus, but not so low as to compress the adjacent cardiac conduction
system.
When the device is appropriately positioned, the implanting physician should coordinate a long
cine-fluoroscopic run. For balloon-expandable valves, we advocate a slow, controlled inflation to ensure
proper valve position. Maximal inflation should be held for 3 to 4 seconds before deflation. It is
important that pacing begins before balloon inflation and continues uninterrupted until the balloon is
near complete deflation. Successful rapid pacing with 1:1 ventricular capture at 180 to 220 bpm will
lower the blood pressure below 60 mm Hg, and prevents forceful contractions that may lead to
inadvertent ejection of the valve prosthesis.
Self-expanding valves, such as the CoreValve system, do not commonly require rapid ventricular
pacing during deployment. Pacing at a lower rate (100 to 120 bpm) has been advocated by many
practitioners to mildly lower the blood pressure during the final stages of valve deployment. The
CoreValve has the benefit of becoming functional before the valve is completely deployed. This allows
for aortography and assessment of valve function while a degree of repositionability still exists.
Following deployment of the valve, positioning and function is assessed by echocardiography and
aortography. A trace or mild amount of paravalvular leak is expected after TAVR. If there is more than
mild leak around a correctly positioned valve, postdeployment balloon dilation using the balloon on the
delivery catheter may further expand the valve and improve the insufficiency.
Transapical TAVR
The TA-TAVR technique was the primary alternative access site for the PARTNER trial and has so far
been used predominantly with a balloon-expandable valve. In those patients with severe peripheral
vascular disease, the TA approach is a very expeditious procedure. This technique represents the only
antegrade approach that is regularly employed. We particularly favor a TA approach in those with a
prior sternotomy or porcelain aorta. The most feared complication of this approach is bleeding from the
left ventricular cannulation site, but this complication is uncommon and decreases with operator
experience. The only relative contraindications to the TA procedure are severe COPD with an FEV1
%predicted <30% or an ejection fraction <20%.
The patient is placed supine on the operating room table and femoral arterial and venous access is
obtained as previously described. A femoral transvenous pacer is placed in the right ventricle and a
pigtail catheter is placed in the aortic root via the femoral artery. Direct AP fluoroscopy is used to
localize the LV apex and a 4- to 5-cm anterolateral thoracotomy is then made in the fifth or sixth
intercostal space. Once the LV apex is exposed, intravenous lidocaine is administered and two pledgeted
3-0 prolene pursestring sutures are placed just cephalad to the true apex and lateral to the LAD. The
pursestring sutures in the myocardium should be deep stitches, but not transmural to avoid tearing (Fig.
2.2).
The patient is heparinized and the left ventricular cavity is accessed with a needle and a 0.035-inch
wire. Using fluoroscopy, the wire is passed into the left ventricle, across the aortic valve, and into the
ascending aorta. The wire is maintained in the ascending aorta and not allowed to pass into the right
carotid artery to prevent a cerebrovascular accident. A 7-Fr catheter is placed through the left ventricular
apex and across the aortic valve. The 0.035-inch wire is manipulated into the descending aorta using a
right Judkins catheter. The 0.035-inch wire is exchanged for a super-stiff wire (Amplatz super stiff;
Boston Scientific, Natick, MA) and left in the abdominal aorta. The 7-Fr catheter is exchanged for the
appropriate-sized delivery sheath which is positioned 3 to 4 cm inside the LV. BAV can be performed
with or without rapid ventricular pacing, but because the valve is crossed in antegrade fashion,
predilation is not always necessary. The balloon is removed and the valve is placed through the LV
delivery sheath and positioned across the valve. Except for cases that require balloon sizing for choice of
valve prosthesis, we do not commonly perform a BAV in our TA-TAVR cases. Positioning,
deployment, and postassessment of the valve is similar to that as aforementioned in the TF-TAVR
section. The TA approach offers the surgeon exquisite control of valve position and oftentimes, only
subtle movements are required during deployment. After adequate evaluation, all catheters and wires are
removed and the apical sutures are tied down using rapid ventricular pacing. Protamine is administered.
There can be no tolerance for bleeding or oozing of any kind from the cannulation site and any concerns
regarding hemostasis must be addressed prior to chest closure. Once hemostasis has been assured, a
small drain is placed in the left pleural space and the incision is closed in the standard fashion.
Figure 2.2 Transapical approach via anterior minithoracotomy. Insets depict location of apical pursestring and
puncture site as well as appropriate predeployment position for balloon-expanded TAVR.
Transaortic TAVR
The TAo approach is gaining increasing popularity as an alternative access site for both balloon- and
self-expanding valves. The TAo approach is advantageous because it avoids a thoracotomy in patients
with poor respiratory function and may be less painful than the TA approach. Accessing the aorta via an
upper mini-sternotomy incision is a standard approach for minimally invasive valve surgery.
Furthermore, direct aortic cannulation is a procedure that all cardiac surgeons feel comfortable with,
particularly when compared to TA access which is less commonly used.
However, while the TAo approach offers several advantages, it is not appropriate for all patients. The
TAo approach is contraindicated in patients with a heavily calcified or “porcelain” aorta or in an
otherwise hostile mediastinum (i.e., patients with a history of cobalt radiation). It can also be technically
challenging in the setting of a prior sternotomy, especially if the patient has patent grafts from a
previous coronary artery bypass grafting (CABG). Particular attention should be paid to patients with a
prior CABG using a pedicled right internal mammary artery graft. If the artery was brought across
midline anterior to the aorta it can be very easily injured and we would not recommend the TAo
approach in this setting. Thorough review of the preoperative CT scan will help mitigate these potential
complications.
Figure 2.3 Direct aortic approach via upper ministernotomy. Counter incision in neck facilitates delivery sheath
angle.
The patient is placed supine on the operating room table and the lower neck should remain exposed to
allow for a counterincision for the delivery sheath. An angled pigtail catheter from the femoral artery is
placed in the aortic root and a femoral transvenous pacer is placed in the right ventricle. The CT can
provide the adequate information of the relationship of the distal ascending aorta to the sternum, the
extension of calcification, and the distance from the site of cannulation to the aortic root. For the
CoreValve device, this distance is ideally 7 cm to allow enough space for the height of the deployed
valve while allowing adequate insertion depth of the delivery sheath.
A small skin incision below the suprasternal notch extending below the Angle of Louis at the second
intercostal space is made. A mini-sternotomy down to the second intercostal space is performed. Our
preference is to perform the sternotomy as a “J” configuration into the right second intercostal space;
although some perform an inverted “T” sternotomy in the second intercostal space. As with a mini-AVR
approach, pericardial stay sutures will help lift the aorta into the operative field. Once an appropriate site
on the distal ascending aorta is exposed, two aortic purse strings are placed near the base of the
innominate artery. We attempt to cannulate on the greater curve as much as possible as this will help
achieve coaxiality of the valve (Fig. 2.3).
The patient is heparinized to maintain an ACT >250 seconds. A small counterincision is made in the
right lower neck and an 18-gauge needle with a 0.035-inch soft guidewire is used to puncture the aorta.
The needle is exchanged for a 7-Fr sheath, and a multipurpose (MP) catheter with a straight soft wire is
used to cross the valve. This is exchanged for a 260-cm long, 0.035-inch Amplatz extra-stiff J-tipped
guidewire which has an exaggerated pigtail bend at the proximal end. The delivery sheath is advanced
into the aorta to a depth of 2 cm. BAV is performed under rapid ventricular pacing. The balloon is
removed and the valve is placed through the delivery sheath and positioned across the valve.
Positioning, deployment, and postassessment of the valve are similar to that as aforementioned in the
TF-TAVR section. After adequate evaluation, all catheters and wires are removed and the aortic sutures
are tied down under rapid ventricular pacing. Protamine is administered and small flexible chest tube is
placed in the mediastinum. The bilateral pleural spaces should be inspected for signs of pneumothorax,
which can be easily treated at this time. The sternotomy is closed in the standard fashion.
Figure 2.4 Axillary exposure for subclavian TAVR delivery.
Subclavian TAVR
The subclavian approach was popularized as a primary alternative access approach for the CoreValve
device. A subclavian arterial approach provides a few distinct advantages compared to other alternative
access routes. It remains less invasive as it does not require entering the thoracic space and presents an
appealing alternative for a frail, older patient in whom a TF approach is limited by anatomy. In addition,
it is suitable in cases of aortic calcification, or severe ventricular and pulmonary dysfunction which
would limit other alternative approaches.
Standard femoral artery and vein access is obtained as aforementioned. Surgical cutdown for the left
subclavian artery is familiar to most cardiac surgeons. An oblique incision is made in the deltopectoral
groove. The first portion of the axillary artery can be exposed with lateral retraction of the pectoralis
minor (Fig. 2.4). Division of the head of pectoralis minor can be performed with minimal morbidity, if
necessary, to obtain optimum exposure. Great care is taken to avoid injury to the medial and lateral
cords of the brachial plexus, as they often travel in close association with the artery, particularly in its
second portion. The patient is heparinized to maintain an ACT >250 seconds. Use of a synthetic graft in
an end-to-side orientation which is then cannulated with the delivery sheath is favored by some, while
others use direct access via a pursestring suture. Once the sheath is appropriately placed, TAVR
deployment proceeds using the usual protocol of the TAo TAVR. At the conclusion of the procedure
following removal of the delivery sheath, vascular control of the access site is obtained and selective
angiography can be used to confirm vessel integrity at the access site.
The left subclavian approach is preferred since it typically offers a more favorable anatomic route.
Special consideration must be paid to patients with prior CABG and a patent LIMA graft. Concern for
ischemia during valve positioning can be treated by withdrawing the delivery sheath back into the
subclavian artery once the valve is placed in the appropriate predeployment position. Although less
common, TAVR can be performed from a right subclavian approach. This approach can be difficult in
patients whose valve is more than 30 degrees off the horizontal plane. In addition, a large delivery
sheath in the innominate artery may limit flow into the right common carotid artery. In this scenario, we
recommend positioning the sheath tip at the origin of the right subclavian artery and monitoring bilateral
cerebral oximetry.
Less Common Routes

In patients who are not suitable for any of the access routes described above, there are alternatives for
TAVR deployment that have been used in much smaller numbers. These approaches should be
considered only as a last resort when a thorough preoperative evaluation results in clear
contraindications for the more common routes. The approaches described below should only be
attempted by Heart Teams with significant TAVR experience using the standard approaches.
Figure 2.5 Set-up for transcarotid TAVR with depiction of common femoral to distal carotid shunt for cerebral
protection. Inset shows longitudinal arteriotomy with proximal delivery sheath placement and distal carotid shunt in
place.
Transcarotid TAVR
A transcarotid approach can be used if a patient has a right common carotid artery diameter of at least 8
mm or commensurate with the size sheaths recommended by the company. The right common carotid
artery is exposed with a longitudinal neck incision, medial to the sternocleidomastoid muscle. This
incision is lower on the neck than the one used for a carotid endarterectomy since only the common
carotid artery needs to be exposed. Femoral arterial access for aortography and venous pacing wire
placement are performed as previously described. In the contralateral femoral artery, a 16-Fr Fem-Flex
II cannula (Edwards Lifesciences, Irvine, CA) is placed percutaneously. This cannula is connected to
perfusion tubing and a 14/15 Sundt carotid bypass shunt (Covidien, Mansfield, MA). After full
heparinization, the right common carotid artery is clamped proximally and distally, and then opened
longitudinally for a length of 3 cm. The deaired bypass shunt is then placed in the distal carotid artery to
maintain cerebral perfusion (Fig. 2.5). Cerebral oximetry from the left and right hemispheres is
monitored throughout the procedure. Through the proximal carotid artery, a 0.035-inch J-tipped wire
and a 7-Fr introducer are placed into the ascending aorta. An MP catheter and a straight wire are used to
cross the native aortic valve. The remainder of the deployment is similar to the transfemoral approach
with a BAV followed by valve deployment. After completion of the procedure, the carotid arteriotomy
is closed with a synthetic patch or bovine pericardium.
Figure 2.6 Transcaval TAVR. Transcaval crossing with snare, device closure of arteriovenous communication.
Transcaval TAVR
A transcaval approach is possible when the abdominal aorta is sufficiently free of calcific disease. A
contrast CT is used to identify a suitable access point in the infrarenal abdominal aorta. After obtaining
appropriate femoral access, a GooseNeck Snare catheter is advanced into the abdominal aorta. A
0.014-inch stiff guidewire placed inside a 0.035-inch guidewire converter is stabilized by a support
catheter inside a guiding catheter (renal double curve [RDC] or RDC1) and is directed to the appropriate
location. In an orthogonal fluoroscopic projection to align the trajectory, short bursts of cautery directed
through the 0.014-inch guidewire are used to traverse the vessel walls, and the stiff wire is captured by
the GooseNeck Snare (Fig. 2.6). The crossing wire is exchanged for a standard 0.035-inch stiff
guidewire and the delivery sheath is advanced across the caval-aortic tract. TAVR deployment then
proceeds in the standard fashion.
At the completion of the procedure, the communication is closed using a standard nitinol occluder
device. Both ductal occluders and ventricular septal defect (VSD) devices can be used. These devices
are chosen to slightly upsize over the outer diameter (OD) of the delivery sheath. Completion
aortography and venography is performed to rule out persistent retroperitoneal hemorrhage.
COMPLICATIONS
Despite its minimally invasive approach, procedural complications associated with TAVR can be
substantial and are associated with considerable morbidity and mortality. The Valve Academic Research
Consortium-2 (VARC-2) criteria provide standardized definitions for evaluating studies of TAVR use.
As with any surgical procedure, thorough preprocedural planning is of the utmost importance when
trying to minimize complications.
Neurologic
TAVR is unique in that it requires the manipulation of large-bore catheters in the ascending aorta and
aortic arch as well as across a heavily calcified aortic valve. This coupled with balloon expansion and
fracture of the calcified aortic leaflets likely represents the etiology for the bulk of acute neurologic
events. The incidence of cerebrovascular events during the 30-day period after TAVR ranges from 3%
to 7%. The majority of these (50% to 70%) are periprocedural and occur within 24 hours of the
procedure. The original PARTNER study demonstrated an increased incidence of periprocedural stroke
following TAVR when compared to SAVR, and a recent meta-analysis compiled an overall 30-day
stroke rate of 3.3 ± 1.8. The type of device used does not seem to impact stroke incidence, but increased
operator experience does correlate with lower event rates.
Given the temporal relationship of neurologic events to the procedure itself, a baseline neurologic
examination should be performed promptly upon arrival to the ICU. Weaning of sedation should be
performed as quickly as the clinical condition allows to facilitate serial examination. Evidence of a new
neurologic deficit should be managed in the standard fashion. Oral antiplatelet therapy
(ASA/clopidogrel) should be initiated as soon as it is considered safe with regards to postoperative
bleeding.
Since much of the embolic phenomena are periprocedural, there have been multiple new technologies
developed to minimize neurologic sequelae. These devices can be categorized in two broad categories:
Deflectors which prevent passage of emboli to the cerebrovascular system by redirecting them to the
lower half of the body and filtration/ retrieval devices which capture and collect emboli for removal
from the systemic circulation.
The most successful device thus far has been the Montage Dual Filter (Claret Medical, Inc.) which is
currently in clinical trials in the United States. The two main deflector devices, the Embrella (Edwards
Lifesciences) and the Triguard (Keystone Heart, Ltd.) also represent other devices used in Europe. All
three devices have been used in small patient series with acceptable results and excellent success with
deployment and retrieval. However, larger randomized trials are needed to determine their clinical utility
for the TAVR population.
Vascular
Complications related to the arterial access site have been a frequent problem since the early days of
TAVR therapy. Direct vascular injury is primarily related to the large-diameter sheaths needed to deliver
the valve. Data from the original PARTNER trial spotlighted the significance of this problem. For the
high-risk cohort A patients, major vascular complications occurred in 11% of TAVR patients compared
to 3.2% in SAVR patients. In the nonoperative cohort B patients, 16.2% of TF-TAVR patients had a
major vascular event within 30 days compared to 1.1% of patients randomized to standard medical
therapy. The implications of these complications are significant with a four-fold increase in 30-day
mortality (14.1% vs. 3.1%) demonstrated in the PARTNER patients.
Transfemoral access with poor hemostatic control may develop a retroperitoneal hematoma that could
go undiagnosed at the bedside. If this is suspected, it must be diagnosed and treated expeditiously. A CT
scan will readily demonstrate the bleeding. In some institutions, organized protocols dictate a return to
the hybrid operating room or cardiac catheterization laboratory with angiography to evaluate for the
bleeding source. This offers the potential benefit of therapeutic intervention at the same time if a
bleeding source is identified.
Bleeding related to TA access can be significant and may initially manifest as excessive chest tube
drainage. However, in the setting of a clotted chest tube the first indication may be opacification or
“white out” of the left lung field on chest x-ray. Patients with dense pleural adhesions may even present
with tamponade physiology. This should be treated with a return to the operating room and exploration
as passive maneuvers (PEEP, increased tidal volume) are unlikely to control an arterial bleeding source.
Postoperative bleeding after TAo access will present much like bleeding after a standard sternotomy.
Chest tube output as well as an enlarged mediastinal silhouette should alert the clinician to a possible
problem. While bleeding may be related to sternal closure or mediastinal soft tissue, one must remember
that there is an aortic cannulation site which, if it is the culprit, will require a return to the operating
room and definitive surgical closure.
Vascular complications are not limited solely to access site bleeding. Perforation of either ventricle
related to mechanical trauma has been reported with TAVR. Presentation in the immediate perioperative
period will be consistent with tamponade physiology and readily diagnosed by bedside
echocardiography. Expedient drainage should be performed and persistent bleeding that does not
respond to conservative management should prompt a return to the operating room for definitive repair.
Dissection related to an access site or mechanical trauma anywhere along the arterial tree is also a
consideration. Significant dissection involving the femoral or subclavian artery will present with signs
of arterial insufficiency in the affected limb. Diminished peripheral pulses, delayed capillary refill, and
an asymmetric neurovascular examination should prompt further investigation. Central aortic dissection
site related to TAo access is usually recognized in the operating room but could be confirmed with either
CT scanning or echocardiography in the postoperative period.
Conduction Abnormalities
The close proximity of the native conduction system to the aortic annulus puts it at risk following aortic
valve replacement. Due to the engineering design of TAVR valves, which require the use of radial force
to achieve placement, new conduction abnormalities are seen more frequently than with SAVR. In
addition, the particular design features of the balloon-expandable and self-expanding valves lead to
consistent differences in the need for permanent pacemakers between the two technologies.
A recent meta-analysis of 41 studies involving over 11,000 TAVR patients illustrates this difference
between devices. Among the series of CoreValve implants reviewed, the median incidence of permanent
pacemaker (PPM) placement was 28% compared with 6% for SAPIEN implants. The authors presented
unadjusted estimates which ascribed a 2.5-fold higher risk of PPM need for a CoreValve compared to
SAPIEN. In addition, preoperative first-degree AV block, left anterior hemiblock, and right bundle
branch block were all predictive of an increased need for PPM. The conduction abnormalities are
usually apparent early in the recovery period and more than 90% of the PPM implantations occur within
the first week following surgery.
In the immediate postprocedure period, knowledge of the device implanted and its associated effects
on conduction are mandatory. Part of the exchange in the ICU should include any information regarding
acute changes in conduction during the procedure. A change in conduction should prompt heightened
awareness of possible bradyarrythmias requiring pacing. An experienced TAVR team will leave
temporary venous access in place in patients who are at increased risk. However, the ICU needs to have
a contingency plan in place for rapid pacing support should it become necessary.
Paravalvular Regurgitation
Paravalvular regurgitation (PVR) of some degree has been very common in the early TAVR experience.
A significant difference between TAVR and high-risk SAVR patients in cohort A of the PARTNER
study persisted at 2-year follow-up with more than 50% of TAVR patients having at least mild PVR.
This is significant because even mild residual PVR was associated with a 10% to 15% higher 2-year
mortality. This association between residual PVR and mortality has been confirmed by other authors
with a recent literature review identifying aortic regurgitation (AR) >2+ as a significant independent
predictor of short- and long-term mortality.
Acute transvalvular regurgitation may occur due to incomplete valve closure when the valve is
deployed in the setting of systemic arterial hypotension and this improves when the blood pressure is
increased. The valve also may simply require a brief period of time (minutes) to “warm up” and achieve
full leaflet mobility. A third scenario for transvalvular AR may be due to an over-hanging native aortic
leaflet which can prevent closure of the TAVR valve leaflets. This scenario particularly affected the
first-generation SAPIEN valve, whose default leaflet position was in an open configuration. The valve
relied on back pressure during diastole to close the leaflets and if native tissue impaired the back flow,
significant central AR was present. In this event, the operator would attempt to close the TAVR valve
leaflets by placing a pigtail catheter in each aortic cusp. If this is unsuccessful, another TAVR valve
should be deployed just aortic to the initial TAVR valve in order to adequately displace the native aortic
leaflets. Subsequent generations of the SAPIEN valve (SAPIEN XT, SAPIEN 3) altered the leaflet
design to a “semi-closed” position and this has become less of a problem. The length of the CoreValve’s
stent frame prevents overhanging tissue from altering valve function.
The pathophysiology linking PVR and mortality is an area of ongoing investigation. Most, if not all,
of the newer generation valves have design features to minimize PVR. In addition, the importance of
minimizing PVR is a well-accepted doctrine among TAVR practitioners. Patients with significant (2+
AR) in a valve deployed at the appropriate height can be treated with balloon post dilatation to further
expand the valve into the native valve tissue. If a valve is deployed either too high or too low, a second
valve deployed inside the first can extend the “seal zone” thereby reducing PVR. The risk/benefit of
further intervention to increase the radial force of the valve must be weighed against the possibility of
stroke and annular disruption by the Heart Team. Knowledge of the presence and severity of residual
PVR is an important part of the transition to care in the ICU. Trace or mild PVR will not have much
impact on the immediate postprocedure management. However, PVR of severity of 2+ or greater will
need attention with regard to afterload reduction and possible chronotropic therapy to optimize the
volume status of the left ventricle.
Less Common Complications

Many of the intraprocedural complications related to TAVR have decreased as experience with the
technique has grown. While certain technologic improvements have facilitated this, much of it is simply
attributable to growing experience with what is essentially a very new technique. The following
intraprocedural complications may still occur, but they have become less frequent as operators have
become savvier with the potential pitfalls of the TAVR procedure.
Valve Embolization
Valve embolization most commonly affects balloon-expanded valves and is typically due to the loss of
pacing capture during deployment. However, it can affect both types of valve if they are badly
malpositioned or grossly undersized. Avoiding valve embolization begins with meticulous
multimodality imaging (multislice CT and TEE) coupled with thorough understanding of the sizing
requirements of the valve to be implanted. Confirmation of reliable pacing capture prior to valve
deployment is mandatory. Careful valve positioning using a slow, controlled deployment will help the
operator make subtle adjustments to ensure the best possible location for the valve.
In the event of gross malpositioning, maintaining wire access is of paramount importance. This will
allow the valve to be recaptured with a balloon and repositioned distally. Typically, a safe location is
anywhere distal to the left subclavian artery in the descending thoracic aorta or immediately proximal to
the common iliac bifurcation in the abdominal aorta. After the embolized valve is secured, a second
valve may be implanted in the annulus to complete the TAVR. Valve embolization into the left ventricle
is less common and almost always requires surgical intervention for removal.
Coronary Occlusion
Myocardial infarction is a rare, yet catastrophic complication during TAVR and occurs in less than 1%
of patients. Acute, aorto-ostial coronary occlusion may be treated effectively with immediate PCI or
emergent peripheral cardiopulmonary bypass followed by PCI. Left main coronary artery occlusion is
most likely, although right coronary artery obstruction has also been described. Percutaneous
intervention can be facilitated in high-risk cases by placing a 0.014-inch coronary interventional wire
and/or balloon into the coronary artery at risk prior to deployment of the new valve. In the particularly
high-risk scenario, the undeployed stent should be placed in the proximal coronary artery ready to
deploy, if needed. This avoids the scenario of not being able to advance past the stent frame in an
acutely unstable patient.
Anticipation and prevention remain the mainstays of treatment for this highly lethal complication.
Coronary artery orifice <12 mm as determined by a high-definition CT scan should prompt concern. In
such scenarios, performing a BAV with a concomitant root angiogram may also discern the potential for
coronary artery occlusion.
Cardiac Tamponade
Tamponade can result from cardiac perforation of either the right or left ventricle during placement of
the pacemaker, wire manipulation, or by the nosecone of the TAVR delivery system. Large inspiratory
drops in systemic arterial pressure (pulsus paradoxus) suggest a hemodynamically significant effusion
and echocardiography will be confirmatory. Treatment with pericardiocentesis is often all that is needed
since bleeding is often self-limited. However, if it is related to a larger diameter device surgical
exploration may be required.
RESULTS
SAPIEN Valve
The placement of aortic transcatheter valves or PARTNER trial established the significance and
potential “game-changing” effects of TAVR therapy in the United States. The trial was a landmark
study as it represented the first randomized data demonstrating the superiority of TAVR over medical
therapy for inoperable patients. In addition, the noninferiority of TAVR versus SAVR in high-risk
surgical candidates opened the door for widespread TAVR use in this population. Based on the 1-year
outcomes from PARTNER, the SAPIEN valve was approved by the US Food and Drug Administration
for use in patients who were not candidates or were high risk for SAVR.
One arm of the study randomized 358 patients with severe AS who were not candidates for surgery
(cohort B) to TAVR with an Edwards SAPIEN valve versus optimal medical management with balloon
valvuloplasty. A significantly decreased mortality for TAVR patients was seen at 1 year (30.7% vs.
50.7%) and at 2-year follow-up (43.4% vs. 68%). This finding shaped future trials as it was no longer
considered ethical to randomize these patients to medical therapy alone.
The results of cohort A of the PARTNER trial demonstrated that in high-risk patients (STS risk score
of 10%) TAVR could achieve comparable short- and mid-term results to SAVR. 179 were treated with a
procedural success rate of 96.6%. The AVA and mean gradients across the aortic valve were
significantly improved to 1.5 ± 0.5 cm2 and 11.1 ± 6.9 mm Hg at 1-year follow-up (preprocedure AVA
0.6 ± 0.2 cm2 and mean gradient 44.5 ± 15.7 mm Hg; p < 0.001). Mortality was 5% and 30.7% at 30
days and 1 year following TAVR, establishing its superiority to medical therapy (1-year mortality
49.7%; p < 0.001).
Other reports have reinforced the favorable mid- and long-term survival for TAVR. Gurvitch et al.
followed 70 patients (mean STS score 9.6% and EuroSCORE 31.7%) who underwent successful TAVR
utilizing a balloon-expandable valve, and those who survived 30 days were followed for a minimum of 3
years. The authors noted a survival at 2 and 3 years of 74% and 61%, respectively. Correspondingly, the
PARTNER series of 348 TAVR patients (mean Society of Thoracic Surgeons Predicted Risk of
Mortality [STS PROM] 11.8%) had a survival rate of 66.5% at 2 years and 56.4% at 3 years. Similar to
the PARTNER series, they noted no cases of structural valvular deterioration and only one patient
(1.5%) in their series underwent reoperation secondary to endocarditis. The recently reported 5-year
follow-up data from the PARTNER trial continues to demonstrate the benefits of TAVR therapy in
high-risk and inoperable AS patients.
CoreValve
After initial clinical success in Europe and CE Mark designation in 2007, the introduction of CoreValve
to the United States began with a multicenter randomized trial which began in late 2010. The Medtronic
CoreValve US pivotal trial adopted a similar trial design to that of PARTNER trial by targeting AS
patients at high risk or extreme risk for traditional SAVR. The extreme-risk group did not require
randomization since the previous findings from the PARTNER study demonstrated a clear survival
benefit for TAVR compared to medical therapy. Popma et al. reported on 489 patients with a mean STS
risk score of 10.3% and mean age of 83 years and noted all-cause death of 8.4% at 30 days and 24.3% at
1 year. Major stroke was noted to be 2.3% at 30 days and 4.3% at 1 year. Major or life-threatening
bleeding was noted in 36.7% and the need for permanent pacemaker was in 21.6%. The percentage of
patients with moderate or severe PVR at discharge was 10.5%. Interestingly, the investigators noted that
the severity of PVR diminished over time. In fact, 80% of the patients who had moderate PVR at 1
month and survived up to 1 year had a reduction in PVR severity.
In a follow-up study, Adams et al. reported on 795 high-risk patients randomized to either SAVR or
TAVR with severe aortic stenosis. The mean STS risk score was 7.4% and represented a less sick group
than the PARTNER high-risk study which had a mean STS score of 11.8%. The primary endpoint of
all-cause mortality at 1 year illustrated a statistically significant difference between the two groups.
Patients undergoing TAVR had a lower all-cause mortality at 1 year (14.2% vs. 19.1%; p = 0.04).
Permanent pacemaker implantation was higher for CoreValve recipients at 30 days (19.8% vs. 7.1%; p <
0.001) and again at 1 year (22.3% vs. 11.3%; p < 0.001). Once again, investigators noticed an
improvement in PVR over time. In fact, a majority of the patients with moderate or severe PVR at
discharge had improved by 1 year to mild or better. Overall, the study represents the first prospectively
randomized comparison demonstrating improved survival at 1 year for TAVR compared to SAVR. The
most recent 2-year follow-up data validate the 1-year findings, with continued benefits in regards to
mortality and major stroke for TAVR patients.
The early challenges related to pacemaker implants and paravalvular leak have been demonstrated by
others. The UK-TAVR registry recently reported prospectively collected data on TAVR patients
implanted up until December 2009. Of the 452 CoreValve implants included in the study 17.3% had
moderate to severe AR compared to 9.6% of SAPIEN implants (p = 0.001). Furthermore, 24.4%
required permanent pacemaker implantation compared with 7.4% of SAPIEN implants (p < 0.001).
Procedural success was still excellent (98.2%) and 30-day mortality remained acceptable at 5.8%. In the
only randomized trial comparing the transfemoral balloon-expandable (SAPIEN XT) and self-expanding
(CoreValve) valves, Abdel-Wahab et al. recently randomized 240 patients to either valve. They noted a
significantly lower frequency of residual aortic regurgitation based on intraoperative angiography (41%
vs. 18%; p < 0.001) and less frequent need for implanting more than one valve in the SAPIEN patients.
Cardiovascular and overall mortality at 30 days was similar in both groups. They also noted that the
need for a permanent pacemaker was significantly lower in the SAPIEN valve group (17% vs. 38%; p =
0.001).
In general, when compared to SAVR, TAVR has been shown in high-risk surgical patient population
to have similar mid-term mortality. An important observation of the aforementioned studies is that
despite the relief of aortic stenosis, this high-risk patient cohort continues to have a progressive
mortality reaching 40% to 45% at 3 years. Although this may be secondary to the inherent comorbidities
and age of this patient population, it remains incumbent for health care providers to redefine the most
appropriate patients for any therapy or TAVR or SAVR.
CONCLUSIONS
Surgical treatment of aortic valve disease represents a mainstay of modern cardiothoracic surgery. Our
understanding of the epidemiology of aortic valve pathology, coupled with projections for worldwide
population growth suggests that the need for therapy will grow substantially in the coming decades. In
the light of the exciting new technology advances, it is important to remember that SAVR represents the
gold standard for all low and intermediate operative risk patients at this time.
The rapid evolution of TAVR is an incredibly exciting development in the field of structural heart
disease. The ability to deliver effective treatment to older patients with more comorbidities represents a
true sea change in the way we view this disease. Over the next few years, in the United States alone we
can expect to see several new valves progressing through clinical trials. Furthermore, technologic
advances will allow us to progressively mitigate the associated risks of the procedure, thereby making it
more appealing for the broader population.
There are currently two trials in the United States, one utilizing SAPIEN (PARTNER 2) and one
CoreValve (SURTAVI), which are investigating the efficacy of TAVR treatment in patients at
intermediate risk for complications (i.e., STS risk of 3% to 8%). The results of these trials will have a
huge impact and how we manage aortic stenosis in the years to come. In addition, new valve types have
been developed for the treatment of primary aortic insufficiency. This requires a different type of
engineering since the calcified, rigid annulus of AS is not present to provide fixation. As this technology
evolves the ability to treat all pathologies related to the aortic valve will become available.
The catheter-based treatment of aortic valve disease represents a rapidly moving target and with each
new technologic advance, associated risks and complications will become apparent. When one stops to
consider that this technology is just a decade old, we can reasonably anticipate a continuous and rapid
evolution that will mandate continued attention.

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meta-analysis of 10,037 published patients. EuroIntervention. 2012;8(1):129–138.
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3
Aortic Valve Repair
Martin Misfeld and Friedrich W. Mohr
Introduction
Aortic valve repair is an old technique, which has been performed since the beginning of open heart
surgery, to treat different aortic valve pathologies. Early results were discouraging due to a lack of
understanding of the underlying valve pathology and the lack of perioperative valve assessment by
echocardiography. The introduction of the latter has made it possible to correctly assess the underlying
aortic valve pathology, more accurately predict the surgical technique to be used, and precisely evaluate
the result of surgical repair.
Aortic valve repair can be divided into the following groups: (1) Restoration of aortic root geometry
with aortic valve sparing techniques (remodeling and reimplantation technique). (2) Repair of individual
structures of the aortic root.
The combination and modification of both techniques is common and is usually individualized to the
valve pathology.
This chapter will focus on reconstructive surgery of isolated aortic root structures. Aortic valve
sparing techniques (remodeling and reimplantation technique) are addressed in Chapter 9.
Anatomy
The aortic root has kindled great scientific interest ever since Leonardo da Vinci (1452–1519) made his
drawings of the aortic root in the 15th century. The aortic root is composed of an annulus proximally
and a sinotubular junction distally with three commissures, interleaflet triangles, sinuses of Valsalva,
and cusps each between them. The cusps were originally named according to their anatomical position
as posterior, right and left (British Terminology Anatomical System) or anterior and right and left
posterior (International Terminology Nomenclatura Anatomica). In the 1950s, surgeons adopted a
simpler terminology of noncoronary, right and left coronary leaflet based on their relation to the
coronary ostia. Although the Nomina Anatomica (1980) describes the atrioventricular valves as having
leaflets and the arterial valves as having semilunar valvules, most of the publications used the term
“leaflets” for the structure suspended in the lumen between the commissures of the aortic root. Figure
3.1 depicts structures of the aortic root.
Figure 3.1 Structures of the aortic root.
Terminology and Definition

Although aortic valve disease is the commonest valvular disorder, definitions of aortic root structures
vary enormously. A clear definition and standardization, as to which segments of the ascending aorta
form a part of the aortic root and which components of the aortic root form the aortic valve, is
mandatory. This will ensure a uniform interpretation of outcome data with respect to clinical
characteristics and surgical techniques, especially if the data is generated by nonmedical personnel.
Therefore, an overall consensus regarding the nomenclature of aortic root structures, which is still
lacking, is necessary.
The following definitions will be observed in this chapter:
Aortic root: Part of the ascending aorta, including the aortic valve and composed of the annulus,
sinuses of Valsalva, sinotubular junction, intercusps, trigones, and cusps.
Aortic valve: Part of the aortic root, composed of three cusps.
Cusps: The mobile components of the aortic valve that separate the aorta from the ventricle.
Annulus: Also called the “functional” annulus. It is a virtual circular ring. Its height is defined
by the nadirs of the semilunar cusp attachments. (The attachment of the cusps to the wall of the
aorta: Semilunar cusp attachment.)
Sinotubular junction: The most distal part of the aortic root at the tip of the commissures.
Sinuses of Valsalva: Bulges of the aortic root, being bordered by the sinotubular junction and
the semilunar cusp attachment.
Commissure: The distal parts of the cusps’ attachment to the aortic wall.
Triangle: The tissue between the cusp attachments and the annulus.
With regard to echocardiography:
Length of cusp coaptation: The maximal length of which two cusps run parallel. Target
length after repair should be >8 mm.
Height of cusp coaptation: The maximal height of cusp coaptation measured from the
level of the “functional” annulus to the free edge of the cusps. The coaptation of the
cusps should be, therefore, longer than the length of cusp coaptation and should start
above the level of the “functional” annulus.
TABLE 3.1 Indications for Surgery in Patients With Severe Aortic Regurgitation
Indications for surgery in patients with aortic regurgitation depend on the following factors:
Severity of regurgitation
Clinical presentation
Indications for concomitant cardiac/aortic surgery
Deterioration of left ventricular function/enlarging dimensions
Indications for surgery as per the AHA/ACC and ESC/EACTS guidelines are mentioned in Table 3.1.
Besides patient factors, the indications for reconstructive aortic valve surgery depend a lot on the
surgical experience of the team performing these procedures. In this context, it is of utmost importance
that an accurate assessment of the quality of the tissue (cusps and aortic root) is made by an experienced
surgeon, so as to achieve long-term durability after aortic valve repair. Therefore, any calcification,
severe fibrosis, and/or aortic wall thinning should be carefully addressed and, if possible, corrected
during the repair.
Contraindications for aortic valve repair are the same as for any patient undergoing cardiac surgery
and depend upon individual judgment of the surgeon and the expertise of the center performing the
surgery.
Role of Echocardiography
Intraoperative transesophageal echocardiography is mandatory during aortic valve repair surgery. It
involves the preoperative assessment of the aortic valve and the evaluation of the repair before the
patient leaves the operating room.
Preoperative assessment of the underlying mechanism of aortic valve regurgitation as well as the
evaluation of tissue quality (i.e., calcification, fibrosis, aortic wall thickness) enables the surgeon to plan
the operation.
The important echocardiographic parameters related exclusively to the aortic valve and root are as
follows:
Calcification and/or fibrosis of the cusps and/or aortic root
Dimensions of the aortic root at annular, mid-sinus, and sinotubular level
Aortic root geometry
Cusp mobility
Identification and classification of bicuspid aortic valves (BAVs)
Severity of aortic regurgitation
The direction of the regurgitant jet as assessed by color Doppler (central, eccentric)
The final decision regarding the suitability of the aortic valve for repair can only be made on valve
inspection, when the tissue quality and aortic root geometry can be visually evaluated.
Intraoperative echocardiography is extremely important to identify and quantify residual valvular
regurgitation following aortic valve repair. A residual aortic regurgitation >grade I should not be
accepted, as it is a predictor of recurrence of severe aortic valve regurgitation over time. The
echocardiography should, therefore, focus on the grade and characteristics of residual regurgitation, cusp
mobility, and, therefore, on the absence of relevant aortic valve stenosis, and the length, plane, and
height of leaflet coaptation. The length of coaptation should be 8 mm, and the plane of coaptation should
be above the annular plane, so that the height of coaptation is longer than the length of coaptation!
Echocardiographic data and indications for aortic valve reconstruction for chronic aortic regurgitation
are depicted in Figure 3.2.
Figure 3.2 Echocardiographic data and indications for aortic valve reconstruction for chronic aortic regurgitation. AR,
aortic regurgitation; AVR, aortic valve replacement (valve repair may be appropriate in selected patients); ERO,
effective regurgitant orifice; LV, left ventricular; LVEDD, left ventricular end-diastolic dimension; LVEF, left ventricular
ejection fraction; LVESD, left ventricular end-systolic dimension; RF, regurgitant fraction; RVol, regurgitant volume.
(Modified from Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guidelines for the management of patients
with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force
on Practical Guidelines. J Am Coll Cardiol. 2014;63:e57–e185, with permission.)
Medical Therapy
Patients with severe aortic valve regurgitation remain asymptomatic for a long time. Mild aortic
regurgitation usually does not need any medical therapy. Although it does reduce afterload in patients
with moderate or severe aortic regurgitation, the use of calcium channel blockers and
angiotensin-converting enzyme inhibitors in asymptomatic patients with moderate or severe aortic valve
regurgitation have not shown any beneficial effect in the absence of arterial hypertension. However,
beta-blockers are recommended in patients with ascending aortic aneurysms to prevent/decelerate the
progression of aortic dilatation.
Patients undergoing aortic valve repair for aortic regurgitation should undergo standard preoperative
investigations including echocardiography, a coronary angiogram (to rule out coronary artery anomalies
and disease and assess the length of left main stem: Selective cardioplegia in case of short left main),
lung function tests, a carotid Doppler, laboratory blood tests, and chest x-ray as well as clearance from a
dentist and an ear, nose, and throat physician regarding chronic infectious foci.
While acquiring an informed consent, the probability of aortic valve repair, its long-term outcomes,
the risk of reoperation and the type of aortic valve prosthesis in the eventuality of repair failure should
be discussed in detail with the patient. The need for lifelong anticoagulation in case of mechanical valve
replacement and the necessity of endocarditis prophylaxis also need to be addressed.
SURGERY
Aortic valve repair can be performed through a standard median sternotomy or through a minimally
invasive partial sternotomy/thoracotomy. The surgical access depends on the surgeon’s expertise in
performing these techniques. The heart and ascending aorta are exposed in a standard fashion followed
by initiation of cardiopulmonary bypass with modifications in cannulation sites according to the surgical
access.
Aortic valve repair is most commonly performed for isolated aortic valve regurgitation. However, in
some cases, an additional stenotic component can also be addressed by repair techniques involving
shaving and/or commissurotomy. Even in cases with predominant aortic valve stenosis, repair
techniques using bovine pericardium have been described. These techniques are not widely used
because of excellent long-term durability achieved by prosthetic valve substitutes. Complete leaflet
replacement using pericardium is a type of aortic valve replacement. Therefore, this technique is not
described in this chapter.
Surgical Exposure
An adequate exposure of the aortic root is crucial. Therefore, the geometry of the aortic root should be
preserved while assessing the aortic root pathology. Hence, the aortic incision should be made 1 cm
distal and parallel to the sinotubular junction. The exposure of the valve can be further optimized by the
use of retraction sutures at the level or above the commissures (Fig. 3.3).
Surgical Techniques
An understanding of the pathomechanism of aortic valve regurgitation is essential before commencing
with aortic valve repair. As “normal” aortic valves are seldom witnessed by a surgeon during cardiac
operations, understanding aortic root geometry, valve morphology, and interactions between various
aortic root structures is challenging. A careful inspection of the aortic root tissue quality and cusps for
presence of fenestrations, which are usually seen adjacent to the commissures, is made. The surgical
techniques target the following structures of the aortic root:
Figure 3.3 Retraction sutures at the level of the commissures for optimal valve exposure.
1. Cusps
2. Annulus or ventricular/aortic junction (“functional annulus”)
3. Sinotubular junction
Stabilization of the annulus to preserve long-term durability of the repair is particularly important.
Various techniques have been described to reconstruct these three key structures:
1. Commissurotomy and leaflet shaving
When cusp quality and mobility is acceptable and fibrosis is limited to small lengths of its free
margin, cusp-shaving maneuvers utilizing a scalpel (no. 11) may be used. Care has to be taken
not to perforate the cusps. A sharp commissurotomy may also be adequate when fusion of two,
otherwise mobile, cusps is limited to the commissural area (Fig. 3.4).
2. Cusp plication
Prolapse of one or more leaflets is the commonest cause of aortic valve regurgitation and
occurs in isolation or in combination with a distorted aortic root geometry with or without the
presence of a BAV.
Assessment of the appropriate length of the free margin of the prolapsing cusp is the key to a
successful reconstruction in this pathology. Two 6/0 or 7/0 monofilament stay sutures, each
placed through the central point (nodulus of Arantius) of the nonprolapsing and prolapsing
cusp help to identify the length by which the free margin of the prolapsing cusp has to be
shortened (Fig. 3.5). A 6/0 or 5/0 monofilament suture may be used to plicate the excessive
length with or without pericardial reinforcement (Fig. 3.6). Such plication often results in a tiny
gap in the central closure line of the valve, which can be overcome either by plicating the free
margin of the cusp in the commissural area or by inserting a small piece of pericardium at the
central point of the line of coaptation of the cusps as an “artificial” nodulus of Arantius.
Figure 3.4 Commissurotomy.
Figure 3.5 Stay suture in the ventral aspect of the nonprolapsing leaflet for adjusting the adequate length
of the free margin of the prolapsing leaflet.
Shortening of the free edge of the prolapsing cusp may also be achieved by using a running
6/0 polytetrafluoroethylene (PTFE) suture along the free edge from one commissure of the
prolapsing cusp to the other. This suture is secured by a Teflon or pericardial pledget outside
the aortic root at the level of the commissures. Care has to be taken not to overcorrect the free
margin of the prolapsing cusp, resulting in restriction and ensuing residual aortic regurgitation (
Fig. 3.7).
Following repair, the length of coaptation, the equality in height of the free margins, and
mobility of the cusps should be assessed. A saline test, which is a rough estimate of the
competency of the aortic valve, is performed to see if the valve can support a small column of
saline without letting it escape through the closure line. Furthermore, creation of a vacuum in
the left ventricular outflow tract by inserting a small suction cannula through the central point
of the aortic valve closure line, thus enhancing cusp coaptation, may also help to judge the
repair.
Figure 3.6 Plication of a prolapsing leaflet in the area of the nodulus of Arantius.
Figure 3.7 Reinforcement of the free margin of a prolapsing leaflet.
3. Patch plasty and patch augmentation

Isolated defects in the cusps caused by endocarditis or fenestrations can be treated with patch
reconstruction. An adequately sized autologous pericardium is harvested and used for closing
the defect with a 6/0 monofilament suture. The patch may be fixed with glutaraldehyde before
use.
Patch augmentation of one or more leaflets can be performed with fixed or unfixed
autologous pericardium. An adequately sized pericardial strip is used to extend the height of
the cusp. The pericardial strip is sutured to the free margin of the cusp with a 6/0 monofilament
suture starting at the nodulus of Arantius. A stay suture may be passed through the nodule of
Arantius of each cusp to accomplish adequate apposition of the three cusps, thus facilitating the
suturing of the pericardial strip. It is secured to the aortic wall at the level of the commissures
with an additional transmural pledgeted 5/0 monofilament suture (Fig. 3.8).
Figure 3.8 Leaflet extension by patch augmentation and leaflet repair with patch plasty.
Figure 3.9 Subcommissural annuloplasty.
4. Annuloplasty
The aim of an annuloplasty is to reduce the circumferential length of the aortoventricular (AV)
junction or “functional” annulus. In the absence of relevant annular dilatation, subcommissural
plication sutures can be used to secure the annular dimension. A horizontal mattress pledgeted
4/0 or 5/0 monofilament or 4/0 braided multifilament suture passing under each commissure
from one sinus to the adjacent one reduces the angle at the apex of the intercusp triangle. The
sutures have to be positioned more superficially in the area of the membranous septum to avoid
damage to the conduction system (Fig. 3.9). Care also has to be taken to avoid cusp injury.
These simple plication sutures, however, do not stabilize the annulus throughout its
circumference. Therefore, either a strip of pericardium or prosthetic material or commercially
available rings can be used to remodel and reinforce the annulus externally. To accomplish
this, the aortic root should be dissected proximally up to the level of the annulus. Careful
dissection is required in the region under the left and right coronary sinuses to avoid injury to
the left and right coronary arteries, respectively. A simple running PTFE suture (CV-0) may
also be used in the form of a purse string suture, brought in and out through the annulus. This
suture is then knotted over a piece of Teflon for reinforcement outside the aorta over a Hegar
dilator of adequate size (21 to 25 mm) passed through the aortic valve orifice (Fig. 3.10).
5. Stabilization of the sinotubular junction
A dilated sinotubular junction causes aortic valve insufficiency in patients with an ascending
aortic aneurysm. Aortic valve competency can be easily achieved by supracommissural
replacement of the ascending aorta with an appropriately sized vascular graft. Additional
annular dilatation or cusp prolapse, which may occur after the aorta has been replaced, should
be corrected. Aortic valve competency before and after repair can be assessed by checking for
left ventricular dilatation after administration of cardioplegia into the prosthetic graft.
Bicuspid Aortic Valves

BAV is the commonest congenital cardiac anomaly. It is assumed that up to 2% of the general
population is affected with predominance among men. Controversy still exists as to whether aneurysmal
dilatation of the ascending aorta in patients with BAV is related to genetic factors, flow dynamics, or
both. Different forms of ascending aortic aneurysms and various types of BAV may represent a
heterogeneous pathologic group.
Figure 3.10 Annuloplasty for correcting annular dilatation. Inset: position of the suture in relation to the “functional”
annulus and leaflets. A: Surgeons view. B: Correct plane of annuloplasty.
One-quarter of all people with BAVs develop aortic valve disease, predominantly stenosis. Patients
with aortic regurgitation have a BAV in up to 29% of the cases.
A broadly accepted classification of BAV was introduced by HH Sievers (Table 3.2). The use of this
classification enables a uniform comparison of clinical data and surgical treatment. However, it does not
include information regarding cusp tissue quality such as cusp restriction, calcification, or fibrosis.
The surgical technique to repair BAV follows the same principles as those used in repair of tricuspid
aortic valves. The tissue qualities of the cusps and the aortic wall have to be assessed before repair.
Achieving an adequate length of cusp coaptation, mobility, and height are also the key fundamentals in
repairing BAVs. In the presence of a raphe, resection of the fibrotic tissue to improve cusp mobility is
mandatory. A 6/0 monofilament continuous suture or interrupted sutures can be used for reattachment of
the cusp, after the fibrotic tissue has been resected.
TABLE 3.2 Classification of Bicuspid Aortic Valves
The postoperative management is the same as that for any patient undergoing aortic valve surgery.
Indications for vasodilators and/or beta-blockers depend on the grade of ventricular dysfunction and the
presence of connective tissue disorders that could or have affected the aorta.
Anticoagulation is usually not necessary in patients undergoing aortic valve repair. Antiplatelet
therapy for 3 months postoperatively is adequate in the majority of cases. However, in some complex
cases, anticoagulation with Coumarin derivatives may be considered for a limited time period.
Endocarditis prophylaxis is necessary according to the current guidelines.
RESULTS
The results of aortic valve repair depend on two factors: Tissue quality at the time of surgery and the
immediate result of repair. The latter one involves the absence of more than trivial residual aortic valve
regurgitation with an adequate length and height of leaflet coaptation and cusp mobility in the absence
of relevant aortic valve stenosis.
Compared to aortic valve replacement, the incidence of thromboembolic events and endocarditis (less
than 0.2%) are lower after aortic valve repair. The incidence of AV block is also lower compared to
conventional aortic valve replacement, but is dependent on the surgical technique used.
In experienced centers, freedom from reoperation has been reported to be up to 98% at 5 years and up
to 95% at 10 years. Freedom from aortic regurgitation grade II has been reported to be 97% at 5-year
follow-up and 90% at 10-year follow-up.
Residual aortic regurgitation detected by intraoperative transesophageal or early postoperative
echocardiography has been shown to be a strong predictor of progression of regurgitation over time. The
same is also true for a coaptation length <8 mm and a plane of coaptation below the level of the annulus.
Regular follow-up of patients after aortic valve repair is mandatory.
CONCLUSIONS
Aortic valve repair has become a useful option with excellent long-term outcomes in patients with
isolated aortic regurgitation. Perioperative assessment of the underlying pathology and result of repair
by an experienced echocardiographer is mandatory. Surgical expertise with careful evaluation of the
anatomy and suitability of tissue quality for a repair are essential before standardized techniques of
valve repair are applied. The potential outcome and durability of the repair should be observed in the
context of excellent long-term performance of bioprostheses valves. Since complications like
endocarditis and thromboembolic events seem to be less after aortic valve repair, preservation of the
native valve should be the initial aim of surgery.
The outcome depends on specific parameters such as good tissue quality, length of cusp coaptation 8
mm, height of coaptation longer than the length of coaptation, plane of coaptation above the annular
plane, no or trace residual regurgitation, and unrestricted leaflet mobility, respectively. These parameters
should be targeted during repair and any compromise needs to be avoided.

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Thorac Cardiovasc Surg. 2013;145:S30–S34.
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techniques and clinical outcomes. J Thorac Cardiovasc Surg. 2009;137:286–294.
Carr JA, Savage EB. Aortic valve repair for aortic insufficiency in adults: A contemporary review and comparison with
replacement techniques. Eur J Cardio-thorac Surg. 2004;25:6–15.
Jeanmart H, de Kerchove L, Glineur D, et al. Aortic valve repair: The functional approach to leaflet prolapse and valve-sparing
surgery. Ann Thorac Surg. 2007;83:S746–751.
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outcome. Circulation. 2013;128:854–863.
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pericardium. J Thorac Cardiovasc Surg. 2014;147:301–306.
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Cardiovasc Surg. 2007;133:1226–1233.
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Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for
cardio-Thoracic Surgery (EACTS). Eur Heart J. 2012;33:2451–2496.
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:485–489.
4
Surgery for Hypertrophic Cardiomyopathy
Joonhwa Hong and Hartzell V. Schaff
Indications
Previously, left ventricular outflow tract (LVOT) obstruction in hypertrophic cardiomyopathy (HCM)
was thought to occur in the minority of patients and considered to have little prognostic impact on late
survival. It is now known, however, that fixed or latent LVOT obstruction is present in almost 70% of
symptomatic patients with HCM, and patients with resting gradients of 30 mm Hg or more have reduced
late survival compared to patients with HCM and no LVOT obstruction. Guidelines for treatment of
symptomatic patients with obstructive HCM recommend initial medical treatment with beta-blockers,
verapamil, and/or disopyramide. For patients who remain symptomatic or are limited by side effects of
medications, relief of LVOT obstruction should be considered because elimination of the gradient and
associated mitral valve regurgitation will reliably relieve symptoms in over 90% of patients. Successful
operation improves associated mitral regurgitation due to systolic anterior motion (SAM) of the mitral
valve and improves pulmonary artery hypertension.
At present, the main indications for septal myectomy in patients with obstructive HCM are relief of
symptoms and restoring diminished functional capacity. The issue of improving survival of patients with
HCM by relief of gradients is unsettled. But the observational study by Ommen et al. does suggest that
survival of patients following myectomy for obstructive HCM is similar to survival of HCM patients
without obstruction and superior to survival of unoperated patients with obstructive HCM. The possible
beneficial effect of septal myectomy on late survival is supported by other studies showing reduced
incidence of implantable cardioverter defibrillator (ICD) discharges in patients following myectomy
compared to medically treated patients. Septal myectomy may be considered as an alternative first line
therapy in some patients with ideal anatomy, that is, those with isolated or predominant subaortic septal
hypertrophy.
Most clinicians recognize the association between symptoms and fixed LVOT obstruction (gradient
>30 mm Hg), but patients with lesser degrees of resting obstruction may be symptomatic because of
high provocable gradients that become apparent with exercise or other provocative maneuvers such as
Valsalva, inhalation of amyl nitrite, or isoproterenol infusion during cardiac catheterization. Septal
myectomy should be considered in this subgroup also, because relief of latent, provocable gradients
produces the same degree of symptom relief as does myectomy in patients with fixed LVOT
obstruction.
Also, there is a subset of patients with apical HCM and diastolic heart failure. The apical variant of
HCM is relatively uncommon and generally not associated with subaortic obstruction. But when present,
symptoms of dyspnea and angina respond poorly to medical therapy. In some patients with apical HCM,
a major contributor to diastolic dysfunction is a small left ventricular (LV) cavity. Apical myectomy to
enlarge the left ventricle is indicated in patients with apical HCM and diastolic dysfunction due to small
LV cavity size.
Contraindications
Contraindications to septal myectomy in patients with obstructive HCM are similar to risk factors for
other types of cardiac surgery such as advanced age and frailty and concomitant illnesses that limit
expected survival. In these patients, alcohol septal ablation (septal infarction) may be useful.
In most patients, hypertrophic obstructive cardiomyopathy is identified initially by transthoracic
echocardiography, and important features are ventricular morphology and hemodynamics. The surgeon
should identify the level of LV outflow obstruction and its relation to SAM of the mitral valve, as this
will guide the extent of myectomy and surgical approach. In most patients, LVOT obstruction is in the
subaortic area and can be identified on echocardiography by the bright endocardial scar that is the
contact region with the SAM of the mitral leaflets. Some patients will have midventricular obstruction
produced by contact of the anterolateral papillary muscle and the septum, and others may have
multilevel obstruction. It is important to identify any intrinsic mitral valve abnormalities that may
require direct repair at the time of myectomy. Echocardiography can also identify location and insertion
of abnormal papillary muscles.
Cardiac magnetic resonance (CMR) imaging may be helpful in preoperative assessment in identifying
ventricular morphology and SAM. Also, CMR with late gadolinium enhancement (LGE) can aid in
assessing risk of sudden cardiac death. Chan et al. found LGE in 42% of HCM patients overall and in
70% of patients who had sudden cardiac death or were rescued from an event by defibrillation. In this
study, more extensive LGE was associated with greater risk of sudden cardiac death events.
Chest pain is a common presentation in patients with HCM. Assessment of coronary arteries is
indicated in patients who present with angina pectoris and those patients who are undergoing myectomy
and have risk factors for coronary atherosclerosis. Coronary CT angiography (CCTA) has been used in
patients with HCM and can detect coronary calcification, focal stenoses, and myocardial bridging. We
have preferred coronary angiography as the most direct method of assessing coronary artery disease in
patients with HCM who might be candidates for concomitant coronary artery bypass or unbridging of
intramyocardial segments of the left anterior descending coronary artery.
SURGERY
Intraoperative Preparation
Operation for septal myectomy is performed under general anesthesia and routine monitoring lines are
placed including a pulmonary artery catheter for pressure measurement and cardiac output
determination. Intraoperative transesophageal echocardiography (TEE) is helpful to confirm the cardiac
anatomy and assess the mitral valve morphology and function and appearance of the ventricular septum.
Most critical information is determined from the preoperative transthoracic echocardiogram, but the
intraoperative images should be studied by the surgical team to confirm the thickness of the septum at
the contact point to determine the length of septal obstruction, and to assess the LVOT gradient under
anesthesia. To evaluate LVOT obstruction, the TEE probe is positioned as parallel as possible to the
LVOT jet to obtain maximal Doppler velocities. The Doppler maximal instantaneous gradient will be
higher than the peak-to-peak gradient at the same point in the same cardiac cycle. Also, the TEE may
demonstrate papillary muscle abnormalities that were not apparent on the preoperative study.
Bypass Setup and Pressure Measurement

For transaortic and transapical myectomy, a standard median sternotomy is the preferred approach. After
administering heparin and placing the aortic inflow cannula, we measure intracardiac pressures in all
patients. Although the Doppler-derived maximal instantaneous gradient may measure LVOT obstruction
most accurately, in the operating room, peak-to-peak systolic gradient is the easiest to obtain, and the
minimal underestimation of outflow gradient is clinically unimportant. The LVOT gradient is evaluated
twice: Before myectomy 2 to 5 minutes before going on bypass and after hemodynamics are stabilized
following myectomy.
To measure the gradient in the operating room, a 2.5-inch, 22-gauge spinal needle is placed into the
aorta close to the aortic cannula and another 3.5-inch, 22-gauge spinal needle is placed into the LV
through the right ventricular free wall and septum (Fig. 4.1). Pressures from both needles are monitored
and recorded simultaneously. To measure dynamic LVOT pressure gradient, a premature ventricular
contraction is induced by tapping the heart and the higher gradient in the subsequent beat
(Brockenbrough–Braunwald–Morrow sign) is recorded; in some patients, small doses of isoproterenol
are administered to elicit a gradient. The needles are kept sterile for repeated pressure measurement after
myectomy to confirm elimination of the LVOT gradient.
The right atrium is cannulated with a two-staged single venous cannula after hemodynamic
assessment to avoid atrial arrhythmias during pressure measurements. We use normothermic
cardiopulmonary bypass and maintain perfusion pressure 70 mm Hg. The aorta is clamped and cold
blood cardioplegia is infused through an aortic tack vent; we usually use an initial dose of 1,000 mL
because of LV hypertrophy. If necessary, a repeat infusion of 400 mL of cardioplegia is infused directly
in the left coronary ostium after 20 minutes of arrest.
Figure 4.1 After cannulation of the aorta, pressures are measured and recorded from the aorta and the left ventricle.
The dashed line over the aorta indicates the anticipated line of the aortotomy.
Exposure
Excellent exposure of the subaortic septum is a critical step in performing an adequate septal myectomy.
We use a transverse-oblique (hockey-stick) aortotomy beginning just cephalad to the commissure
between the right and noncoronary sinuses (Fig. 4.1). This incision in the aorta continues rightward and
then inferiorly toward the base of the noncoronary sinus, a centimeter or so above the aortic annulus.
The anterior portion of the aortotomy is slightly closer to the sinotubular ridge than is usual for aortic
valve procedures. The aortic valve cusps are gently retracted to the aortic wall. We do not routinely vent
the left ventricle; rather, the assistant uses a cardiotomy sucker as described below.
Exposure of the subaortic septum may be troublesome when the aortic diameter is small. However,
most of the difficulties in exposure are from discrepancy between the axis of the surgeon’s view through
the aortic valve and plane of the ventricular septum. We use several maneuvers to facilitate the
exposure. First, pericardial stitches are used on the right side of the incision but not on the left, so the
left ventricle falls somewhat posteriorly in the thorax. Second, the inferior edge of the aortotomy is
retracted anteriorly with stay sutures of 4-0 polypropylene. Third, a rigid cardiotomy sucker is placed
into the LV through the aortic valve. This sucker is positioned against the commissure between the
noncoronary and left aortic sinuses (Fig. 4.2). Held by the assistant, the sucker aspirates any blood from
the left ventricle and gently depresses the anterior leaflet of the mitral valve away from the operative
field.
Special care must be taken not to injure the aortic valve cusps or the mitral valve leaflets during
exposure, and for this reason we do not place additional retractors through the aortic valve. A final and
important maneuver is pushing the left ventricle posteriorly by depressing the right ventricle with a
sponge stick; this rotates and brings into view the more distal subaortic septum, so the myectomy can be
extended apically to the papillary muscles. It is useful also to elevate the operating table and tilt it
slightly to the left to improve vision beneath the aortic valve.
Figure 4.2 Pledgeted 4-0 polypropylene stay sutures are placed to retract the edge of the aortotomy to facilitate
exposure. A cardiotomy sucker is placed through the aortic valve to depress the anterior mitral leaflet posteriorly
away from the hypertrophied septum. Note that the sucker is positioned at the commissure between the left and
noncoronary cusps to avoid the aortic valve injury.
Figure 4.3 Myectomy begins with the septal incision using a standard no. 10 blade just to the right of the nadir of the
right aortic sinus. The initial incision in the septum (inset) is made upward and then leftward over to the anterior
leaflet of the mitral valve leaving an 8 to 10 mm of muscle immediately below the aortic annulus to prevent aortic
cusp prolapse and regurgitation.
Septal Muscle Excision

After inspection of cardiac anatomy, including identification of the area of mitral–septal contact (usually
marked by a whitish fibrous friction lesion), myectomy begins using a standard no. 10 scalpel blade on a
long handle. The incision in the septum begins just to the right of the nadir of the right aortic sinus. The
width of no. 10 blade (approximately 8 mm) can be used as a reference of incision depth while the
incision is made. The initial incision in the septum is made upward and then carried leftward over to the
anterior leaflet of the mitral valve (Fig. 4.3). Scissors are used to complete the excision of this initial
portion of myocardium (Fig. 4.4). This first excision improves the exposure of hypertrophied septum
more toward the apex and the mitral subvalvular apparatus.
Figure 4.4 The excision of the initial myocardium is completed using scissors.
Figure 4.5 In general, one-half the thickness of septum is resected, while the retained septum is about 1 cm thick.
An important step is excision of the septum toward the apex, and exposure of this area is improved by posterior
rotation of the ventricle. By the posterior displacement of the anterior wall of the left ventricle with a sponge stick (
arrow), the residual hypertrophied septum moves more into the operator’s view. The sponge stick and cardiotomy
sucker are repositioned frequently to maintain exposure of the desired areas of resection.
The area of septal excision is then deepened and, more importantly, lengthened toward the apex of the
heart, being certain to excise hypertrophied septum beyond the endocardial scar (Fig. 4.5). The
myectomy site is further enlarged and deepened with pituitary rongeurs, if required. Adequate septal
myectomy usually yields 3 to 12 g of muscle. During the procedure, the position of the sucker in the LV
and the sponge stick depressing the heart by assistants are adjusted to facilitate the exposure.
Abnormal chords and fibrous attachments of the mitral leaflets to the ventricular septum are divided
or excised (Fig. 4.6). Abnormal papillary muscles may contribute to outflow tract obstruction if the
muscle inserts into the body of the anterior leaflet of the mitral valve. These abnormal papillary muscles
can be safely excised. When the abnormal papillary muscle inserts into the free end of the anterior
leaflet, it rarely contributes to obstruction, and great care should be taken if it is excised because it may
be contributing to the support of the anterior leaflet, and excision may lead to some degree of leaflet
prolapse.
Figure 4.6 After the septal muscle resection is completed, the mitral subvalvar apparatus is inspected and an
additional procedure is performed, if required. In panel A, an anomalous papillary muscle inserts into the body of the
anterior leaflet of the mitral valve. In this location the anomalous papillary muscle may contribute to outflow tract
obstruction and can be safely excised. In panel B, the anomalous papillary muscle inserts into the free edge of the
valve and excision risks creating leaflet prolapse and regurgitation.
The adequacy of myectomy is evaluated by direct inspection and digital palpation and the evaluation
must include the distal extent of the resection. The most common cause of recurrent obstruction and
symptoms are inadequate length of myectomy toward the apex, not inadequate depth, leaving
obstruction at the midventricular level. Overlooked anomalous papillary muscles cause residual
obstruction too. Wide myectomy facilitates the exposure of the papillary muscles and chordae through
the aortic root. The mitral subvalvular apparatus are inspected for additional procedure and possible
injury. The aortic and mitral valves are inspected carefully to ensure that they have not been injured. The
aortotomy is closed in two layers with 4-0 polypropylene sutures. Temporary atrial and ventricular
pacing wires are placed. The patient is weaned from cardiopulmonary bypass as usual.
Inadequate Myectomy
The adequacy of the myectomy is evaluated by pressure remeasurements in the LV and aorta, and by
TEE. In general, we would resume cardiopulmonary bypass for re-resection if the gradient is greater
than 15 to 20 mm Hg. The surgeon should communicate with the cardiologist or the anesthesiologist on
residual SAM or regurgitation of mitral valve. Significant residual SAM or regurgitation of the mitral
valve should be corrected by additional muscle resection or, less commonly, by mitral valve procedure.
We believe that the majority of SAM and related mitral valve regurgitation disappears after adequate
myectomy. Therefore, resuming cardiopulmonary bypass is usually targeted for additional myectomy
unless there is inadvertent damage to the mitral valve. Hypovolemia or anemia are nonanatomic causes
of residual SAM even after adequate myectomy, which is corrected by volume infusion or transfusion.
There are some differences in postoperative management of patients following myectomy compared to
patients who undergo other cardiac surgical procedures. It is important to maintain adequate afterload,
and frequently, infusions of vasopressin or other vasoactive drugs that are helpful for maintaining
adequate peripheral vascular resistance; vasodilating drugs are generally avoided. Maintaining
atrioventricular synchrony is important for adequate filling of hypertrophied ventricles, and atrial
fibrillation may be poorly tolerated; prophylactic treatment with amiodarone and/or beta-blocker drugs
may be helpful. If supraventricular tachycardia leads to hypotension, early d/c cardioversion may be
necessary. Atrial pacing is useful in many patients to augment cardiac output and reduce the risk of
atrial fibrillation. Pain management, fast-track protocol, early ambulation, and discharge strategy are the
same in myectomy patients as in other cardiac surgical patients. We generally restart patients on medical
treatment with the beta-blocker prescribed preoperatively and aim to dismiss the patient on half of the
preoperative dose. We do not routinely restart calcium channel blockers or disopyramide. A
transthoracic echocardiogram is obtained in all patients before hospital dismissal to assess the outflow
tract, cardiac valve function, and to exclude the presence of pericardial effusion.
COMPLICATIONS
In experienced centers, the risk of hospital death after isolated septal myectomy for obstructive HCM is
<1%. Complications, such as iatrogenic ventricular septal perforation, and/or aortic and mitral valve
injury are rare occurring in <2% of patients. Complete heart block requiring a permanent pacemaker is
observed 2% to 3% of patients, but partial or complete left bundle branch block occurs in approximately
40% of patients after myectomy. This does not cause adverse sequelae unless the patient has complete
right bundle branch block preoperatively. Development of left bundle branch block after myectomy in
patients with preoperative right bundle branch block increases risk of complete heart block and the need
for permanent pacing.
RESULTS
Successful septal myectomy significantly improves symptoms and exercise capacity in symptomatic
patients with obstructive HCM with very low operative risk. The majority of severely symptomatic
patients have improved functional classes (New York Heart Association [NYHA] I-II), and dramatic
relief of symptoms such as dyspnea, angina, or syncope. Also, long-term (10-year) survival after
myectomy is similar to that of an age- and gender-matched general population. The risk of appropriate
implantable cardioverter defibrillator (ICD) discharges significantly decrease in patients following relief
of LVOT gradients. Late recurrence of significant LVOT obstruction is very uncommon if the
myectomy is performed with sufficient septal muscle resection depth, length toward the apex, and care
not to leave a midventricular obstruction and/or residual obstruction due to anomalous papillary
muscles. Indeed, we have not observed recurrence of LVOT obstruction due to septal muscle regrowth
in patients with HCM, and this is in contrast with the relatively frequent recurrence of LVOT
obstruction in patients with congenital membranous and tunnel subaortic stenosis.
CONCLUSION
Septal myectomy effectively relieves LVOT obstruction and cardiac symptoms in patients with
obstructive HCM. Associated mitral valve procedures are rarely required, and even when necessary,
correction of mitral valve regurgitation can be managed without replacement. Extended septal
myectomy is a relatively straightforward procedure, but adequate exposure and an understanding of the
mechanisms of obstruction and residual obstruction are keys to successful relief of gradients and
avoidance of complications such as ventricular septal defect, valvular injury, or significant conduction
abnormality. The operation can be performed with very low mortality, morbidity and symptomatic
improvement with myectomy is excellent.

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5
Apicoaortic Valved Conduit
Faisal G. Bakaeen and Denton A. Cooley
Introduction
Aortic valve bypass with a valved apicoaortic conduit is one of the options available to relieve left
ventricular outflow tract (LVOT) obstruction. The concept of creating a double-outlet left ventricle dates
back to early work by Carrell in the early 1900s. Subsequently, largely experimental attempts to create
such a conduit were fraught with limitations relating to hemorrhagic complications at the myocardial
anastomosis and degeneration of the homograft valves. Refinements were introduced in the 1950s and
1970s, and better outcomes were achieved with the use of specialized prostheses. Dr. Cooley, the senior
author of this chapter, and his colleagues built on their vast experimental work involving pumping
prosthesis between the LV apex and the abdominal aorta and saw a clinical application of this technique
through a modified nonpumping prosthetic LV apical–abdominal valved composite conduit.
Cooley et al. emphasized the necessity of rigid thromboresistant LVOT prostheses and described the
use of alternative techniques with or without cardiopulmonary bypass. Their distal anastomosis was
most commonly performed to the supraceliac abdominal aorta; other sites included the infrarenal aorta,
ascending aorta, lesser curvature of the aortic arch, and descending aorta.
The apical-to–descending aortic conduit has gained traction in recent years through work by Brown
and Gammie. In addition, cardiac surgeons have become more familiar with the ventricular apex
because of the increased use of ventricular assist devices and the introduction of transapical
transcatheter aortic valve replacement (TAVR) technologies. These trends have helped revive the use of
the apicoaortic bypass option in select patients with LVOT obstruction.
Indications
Aortic valve bypass with an apicoaortic valved conduit is indicated for patients with severe symptomatic
aortic stenosis or congenital forms of LVOT obstruction who are not suitable candidates for traditional
open surgery. Adult patients often have a porcelain ascending aorta or a hostile mediastinum. Conditions
that create a hostile mediastinum include bypass grafts or cardiac structures that are adherent to the
posterior table of the sternum and are at risk for injury during sternal re-entry, and dense mediastinal
scarring from multiple previous operations or radiation.
Although TAVR is typically used as an alternative to surgical aortic valve replacement (SAVR) in
such high-risk patients, occasionally, TAVR is not possible because of unsuitable anatomic features of
the aortic annulus or root, or because the transcatheter access options are poor.
Contraindications
Anatomically, a heavily diseased or porcelain descending thoracic or abdominal aorta precludes safe
aortic clamping and anastomosis. Physiologically, significant aortic regurgitation is a contraindication
for aortic valve bypass. In addition, a thoracotomy is best avoided in patients with severe chronic
obstructive pulmonary disease.
Surgical access and exposure are compromised in morbidly obese patients. A thick layer of epicardial
fat at the apex adds to the technical difficulty of the apical anastomosis. Also, dense adhesions in the
chest or abdomen can complicate access to the aorta.
Steps taken in the work-up and preparation of the patient for apicoaortic conduits are similar to those
taken in SAVR. Importantly, echocardiography is performed to confirm the LVOT obstruction and to
rule out significant aortic regurgitation. Coronary angiography is performed to rule out
hemodynamically significant coronary artery disease. Pulmonary function tests are particularly
important in patients with a history of pulmonary disease to ensure that they can tolerate thoracotomy.
A computed tomography scan of the chest, abdomen, and pelvis with contrast is important in defining
the chest anatomy, identifying a suitable aortic anastomosis site, and determining whether femoral
access is an option for cardiopulmonary bypass.
SURGERY
As noted earlier, there are a variety of approaches for apicoaortic conduit surgery, the choice of which is
dictated by the site of the aortic anastomosis. For the purposes of this chapter, we will focus primarily
on the procedure most commonly performed today, namely a left thoracotomy approach for an
apical-to–descending aortic bypass.
Positioning and Access for Cardiopulmonary Bypass

The procedure is performed under general anesthesia and, preferably, with the use of a double-lumen
endotracheal tube. A transesophageal echocardiography (TEE) probe is typically inserted in conjunction
with routine monitoring lines. A Swan–Ganz catheter is useful, particularly in patients with depressed
ejection fraction or pulmonary hypertension.
The patient is placed in a right lateral decubitus position with the shoulders at 90 degrees to the table
and the hip at 45 degrees to give adequate access to the left femoral vessels ( Fig. 5.1). If open access to
the left femoral vessel is deemed necessary, the left femoral artery and vein are exposed through a
horizontal skin incision just above the groin crease. A femoral arterial line is placed under direct vision,
tunneled, and secured to the adjacent skin.
Arterial inflow for cardiopulmonary bypass is routinely performed through an 8-mm Dacron graft
(Boston Scientific, Natick, MA). On a side table, this graft is sutured to the apicoaortic conduit, distal to
the valve (see Conduit Assembly). If the need to institute cardiopulmonary bypass arises before the
conduit is anastomosed to the aorta, emergent inflow can be established via the left femoral artery with a
17F or 19F percutaneous cannula with initial wire access through the femoral arterial line.
Figure 5.1 Patient positioning: Right lateral decubitus with access to left femoral vessels.
Venous outflow is achieved by a 19 to 23F percutaneous cannula advanced into the right atrium or
superior vena cava under TEE guidance. Our preference is to place a 5-0 polypropylene purse string
suture through which the venous cannula is deployed via a Seldinger approach. This allows easy closure
of the vein at the time of decannulation.
Conduit Assembly
We currently use the commercially available Medtronic Hancock specialty product (Hancock,
Medtronic Inc., Minneapolis, MN) (Fig. 5.2). Hancock bioprosthetic valved conduits (Model 105)
consist of a porcine aortic valve sutured into the center of a woven fabric conduit ( Fig. 5.2A). It is
recommended that the conduits be preclotted before use to minimize interstitial blood loss. It is available
in sizes of 12 to 22 mm. Another option is to insert a Medtronic “Freestyle” aortic root prosthesis
between the connector and the tube graft components.
Hancock Apical Left Ventricle Connectors (Fig. 5.2B) are curved at a 90-degree angle to facilitate the
turn toward the descending aorta. It is available in sizes corresponding to the valved conduit, but sizes of
16 mm and 18 mm are most commonly used in adult patients.
The proximal end of the valved conduit is sutured to the connector a few millimeters away from the
valve with 4-0 polypropylene suture. Next, a graftotomy is created distal to the valve to which an 8-mm
Dacron graft is sutured with 4-0 polypropylene suture. A 3/8 connector is secured to the free end of the
side graft for connection with the pump tubing.
Figure 5.2 A: Medtronic Aortic Valved Conduit, Model 105. B: Hancock Apical Left Ventricle Connectors, which are
curved at a 90-degree angle to facilitate anastomosis to the descending aorta. C: The Hancock trocar. This device
has disposable stainless steel cylindrical blades and matching tips in sizes corresponding to the outside diameters of
the Hancock Apical Left Ventricle Connectors. The trocar is designed to create a circular ventriculotomy. The
excised myocardial plug is retained within the blade.
In 2012, an automated coring and apical connector insertion kit (Correx, Waltham, MA) received CE
Mark indication to relieve LVOT obstruction in patients with critical aortic stenosis. The kit consists of
two implants: An apical left ventricle connector and a valved conduit. This technology is slated to
facilitate performing aortic valve bypass off-pump, but additional data are needed to confirm its
effectiveness and safety, and this product is currently not available for sale in the United States.
Technique
A left anterolateral thoracotomy incision is performed at or below the inframammary crease, entering
the chest via the 6th or 7th interspace after the left lung is collapsed. Transthoracic echocardiography
may be helpful in locating the apex before the incision is made. The rib is divided posteriorly, and the
rib retractor is gradually opened. We typically start with a small incision and divide the rib only after we
are satisfied with the level of the entry. To achieve adequate exposure of the apex, the ribs may be
shingled medially. The inferior pulmonary ligament is divided to expose the descending aorta.
The pericardium is divided at the apex to expose a suitable site for the connector insertion. This is
done 1.5 to 2 cm lateral to the left anterior descending artery, and the connector’s insertion site can be
confirmed by TEE. The site should be lateral to the septum and away from the mitral apparatus.
Removal of some epicardial fat may be necessary in a particularly fatty apex. Preoperative computed
tomography may be helpful in anticipating a fatty apex. The goal is to expose myocardium in that area
that would hold sutures well. In some redo scenarios in which the pericardium is densely adherent to the
epicardium, this dissection may be limited to an area slightly larger than the size of the connector, and
the securing sutures may incorporate the adherent pericardium.
Aortic Anastomosis
A suitable aortic anastomotic site is identified by preoperative imaging and confirmed by palpation or
epiaortic echography. The parietal pleura in the area of interest is divided to expose the aorta, and the
segmental intercostal arteries are left intact.
The assembled conduit is brought into the operative field and measured to suitable length. A partial
clamp is then applied after a 5,000-IU loading bolus of heparin is administered. The femoral arterial
pressure is checked to ensure adequate distal perfusion.
An aortotomy is then created that is slightly smaller than the graft diameter. Next, the anastomosis is
constructed with running 4-0 polypropylene suture (Fig. 5.3). Interrupted pledgeted sutures may be used
if there are concerns about the quality of the aorta or if exposure is difficult. The partial clamp is
released after the anastomosis is completed, and additional sutures are placed as necessary to secure
hemostasis. It is critical that hemostasis be ensured at this stage because it is more difficult to access
bleeding areas after the ventricular anastomosis is completed. Any stasis of blood in the graft should be
avoided before full heparinization.
Ventricular Anastomosis
Although it can be performed off-pump, our preference is to create this anastomosis on-pump (Fig. 5.4).
At this point, an additional dose of heparin is given, and cardiopulmonary bypass is initiated after the
conduit is deaired. The appropriately sized Hancock trocar’s cylindrical blade (Fig. 5.2C) is then pressed
gently against the apex to mark the site of the connector. Six to eight 2-0 double-armed monofilament
sutures with MH needles and large Teflon pledgets are placed in a circumferential fashion in a
horizontal mattress pattern. Almost full-thickness bites of the myocardium are taken. The sutures exit
just outside the previously marked myocardial circular area and are then passed into the sewing ring of
the apical connector.
Figure 5.3 Aortic anastomosis. A partial clamp is applied after heparin is administered and the assembled and
premeasured conduit is sutured. Inset demonstrates the preassembled conduit.
With the patient in steep Trendelenburg position, a stab wound is created at the center of the circular
area of interest and enlarged to allow the deployment of the Hancock trocar. This trocar is designed to
create a circular ventriculotomy and retain the excised myocardium within the blade. The apical
connector is then inserted into the ventricle and tied in place. After meticulous deairing of the conduit, a
clamp previously placed proximal to the inflow side graft is removed, allowing blood to flow from the
apex to the aorta. Additional hemostatic sutures are added as necessary, ideally with the heart
decompressed, before bypass is discontinued.
Figure 5.4 Ventricular anastomosis: We prefer to perform this anastomosis on-pump, using the 8-mm Dacron graft
for arterial inflow. This allows a more controlled and precise insertion of the connector.
Figure 5.5 Alternative construction with aortic anastomosis at the supraceliac aorta.
Closing
Direct pressure measurement of the ventricle confirms the hemodynamic success of the procedure and
rules out potential obstruction that could be caused by ventricular muscle—a scenario that might arise if
the coring mechanism was incomplete or if a connector was malpositioned. Protamine is administered to
reverse heparinization, and hemostasis is ensured. Vancomycin powder is sprinkled on the graft, and the
chest is closed in a routine fashion after chest tubes are placed. An intercostal block or placement of an
ON-Q pump helps with postoperative pain control.
Alternative Approach
If the sternotomy is not of high risk, and in the absence of a hostile mediastinum, a median sternotomy is
extended into the level of the umbilicus. The stomach and transverse colon are retracted downward and
to the left, the triangular ligament is divided, and the left lobe of the liver is retracted toward the right,
exposing the supraceliac aorta beneath the diaphragm. The right crus of the diaphragmatic hiatus is
divided to expose 5 to 8 cm of the supraceliac abdominal aorta. Umbilical tapes are passed around the
exposed segment of the aorta proximally and distally to enhance exposure. A partial clamp is applied,
and the aortotomy and anastomosis are performed as they are for the thoracic aorta (see above). The
apical anastomosis is performed on-pump with or without cardiac arrest. The conduit is passed through
an aperture in the diaphragm, allowing for a gentle curvature as it traverses from the apex of the heart to
the aorta (Fig. 5.5).
Routine postoperative cardiac care is instituted. It is important to avoid severe hypertension that could
result in bleeding complications, especially at the ventricular anastomosis. Early extubation is
encouraged, along with aggressive pulmonary toilet and physical therapy to diminish pulmonary
complications and enhance the overall recovery. Pain control is vital and can be facilitated by
administration of local anesthetic to achieve a nerve block intraoperatively, or by the use of surgical pain
pumps. Patients are prescribed aspirin for life and do not need anticoagulation.
Echocardiography is best performed at clinic follow-up at about a month after surgery to allow
postoperative anemia to correct and to allow the patient’s hemodynamics to reach a new steady state. It
is recommended that surveillance echocardiography be performed annually, or more frequently, if there
are changes in signs or symptoms.
COMPLICATIONS
Bleeding is the most common complication and is typically encountered at the apical anastomosis
because the fleshy myocardial tissue is vulnerable to tearing. In addition to acute bleeding,
pseudoaneurysms may develop at the site of the anastomoses. Conduit kinking is minimized by
appropriate conduit lay and length measurement. Good technique can reduce the risk of flow obstruction
relating to muscle bulk from inadequate coring of the apex or malpositioning of the conduit. Other
complications include cardiac dysrhythmia, myocardial ischemia, stroke, atheroembolism, aortic
dissection, renal failure, and infection.
Although there is a theoretical risk of thrombotic complications at the root, echocardiography, cardiac
magnetic resonance imaging, and finite element analysis show that blood flow after aortic valve bypass
surgery is highly predictable, with one-third of the stroke volume ejected through the native valve and
two-thirds through the conduit. Thus, the risk of stagnation and thrombosis is low.
RESULTS
The literature regarding aortic valve bypass is limited to case reports and small case series from select
centers. Aortic bypass produces effective hemodynamic relief causing a significant drop in the gradient
across the native aortic valve. The perioperative morbidity and mortality rates are acceptable in this
high-risk patient population, and reports show improved outcomes with increasing experience. Little
data exist regarding long-term outcomes.
New technologic adjuncts are being developed to facilitate the construction of the bypass. These
could potentially reduce the requirement for cardiopulmonary bypass and limit the invasiveness of the
procedure.
CONCLUSIONS
Aortic valve bypass with an apicoaortic conduit is a useful technique in the armamentarium of a surgeon
caring for patients with aortic stenosis with challenging anatomic scenarios, or patients with complex
LVOT obstructions.

Adams C, Guo LR, Jones PM, et al. Automated coring and apical connector insertion device for aortic valve bypass surgery.
Ann Thorac Surg. 2012;93:290–293.
Brown JW, Girod DA, Hurwitz RA, et al. Apicoaortic valved conduits for complex left ventricular outflow obstruction:
technical considerations and current status. Ann Thorac Surg. 1984;38: 162–168.
Cooley DA. Left ventricular-aortic valved conduit for obstructed left ventricle outlet. In: Wu Y, Peters RM, eds. International
Practice in Cardiothoracic Surgery. Boston: Martinus Nijhoff; 1986:804–812.
Crestanello JA, Zehr KJ, Daly RC, et al. Is there a role for the left ventricle apical-aortic conduit for acquired aortic stenosis? J
Heart Valve Dis. 2004;13:57–62; discussion 62–63.
Gammie JS, Brown JW, Brown JM, et al. Aortic valve bypass for the high-risk patient with aortic stenosis. Ann Thorac Surg.
2006; 81:1605–1610.
Gammie JS, Krowsoski LS, Brown JM, et al. Aortic valve bypass surgery: midterm clinical outcomes in a high-risk aortic
stenosis population. Circulation. 2008;118:1460–1466.
Norman JC, Cooley DA, Hallman GL, et al. Left ventricular apical-abdominal aortic conduits for left ventricular outflow tract
obstructions. Clinical results in eleven patients with a special composite prosthesis. Circulation. 1977;56:II62–II65.
Vliek CJ, Balaras E, Li S, et al. Early and midterm hemodynamics after aortic valve bypass (apicoaortic conduit) surgery. Ann
Thorac Surg. 2010;90:136–143.
6
Access for Aortic Valve Surgery: Minimally Invasive Open
Approaches
Danielle A. Smith and S. Chris Malaisrie
Introduction
The conventional approach to aortic valve replacement (AVR) is through a full sternotomy. Any
approach that does not involve a full sternotomy is considered a minimally invasive approach. The first
minimally-invasive aortic valve replacement (MIAVR) was described in 1993 and performed through a
right thoracotomy. By 1996, the spectrum of minimally invasive techniques also included
hemisternotomies, transverse sternotomies, as well as a parasternal incision. Currently, anterior right
thoracotomy (ART) and upper hemisternotomy (UHS) are the predominant MIAVR approaches.
A direct correlation between clinical outcomes and institutional surgical volume is well established for
conventional AVR. Accordingly, incorporation of MIAVR into surgical practice requires established
expertise in conventional aortic valve surgery and adequate case volume. A caseload of 30 or more
aortic valve-related cases per year is suggested. Moreover, open communication between the cardiac
anesthesiologist, the surgeon, perfusionist, and operating room nurses is essential and the lack of a
dedicated team is a contraindication to MIAVR. The requirements include an experienced cardiac
anesthesiologist adept with transesophageal echocardiography (TEE). Experience with placement of
transjugular coronary sinus catheters is an added benefit. The perfusionist should be familiar with
noncentral cannulation techniques and utilization of vacuum- or kinetic-assisted venous drainage during
cardiopulmonary bypass (CPB) when small cannulae are selected. Finally, the operating room nurses
should be familiar with low-profile retractors, and long-shafted instruments that greatly facilitate
MIAVR.
Patient selection is essential to a successful operation. Longer CPB and aortic cross-clamp (ACC)
times can be expected during MIAVR, without a negative effect on postoperative outcomes. Indications
for MIAVR are similar to those for isolated AVR through a full sternotomy and include aortic stenosis,
aortic regurgitation, and benign aortic valve tumors. Any patient requiring an isolated AVR is, therefore,
a candidate for MIAVR. The only absolute contraindication to MIAVR is the inability to tolerate
increased ACC and CPB times. For example, some patients with severe heart failure or chronic lung
disease may not tolerate even minimally increased operating times.
Several relative contraindications to MIAVR should be considered. Morbid obesity is a relative
contraindication to MIAVR if adequate exposure is not feasible. However, with the appropriate minimal
access retractors, sufficient exposure can be achieved. Patients with chest wall deformities, such as
pectus excavatum and kyphoscoliosis, should be approached with caution when considering MIAVR. In
some patients, UHS should be avoided if the deformity alters the normal position of the heart, deviating
the surgical field into either pleural cavity. Previous right chest surgery is a relative contraindication for
ART given the likelihood of dense pleural adhesions.
UHS is the first logical approach for surgeons starting an MIAVR practice as it can be easily
converted to a full sternotomy. Once UHS is mastered, ART may be considered. Surgeons should have
experience with peripheral CPB prior to incorporation of the ART approach. UHS is the recommended
approach for reoperative AVR in order to safely cross-clamp the aorta and avoid injury to adherent
structures such as the pulmonary artery (PA), left atrial appendage, and any pre-existing bypass grafts.
The ART approach is best suited for patients who may have difficulty following sternal precautions or
who otherwise wish to avoid sternotomy. A thoracotomy is cosmetically best through an incision
slightly superior to the inframammary crease (and not directly through the crease). The entire incision
can then be moved to the desired interspace, which is typically more cephalad. An incision directly into
the third or fourth interspace, that is well above the inframammary fold, may be disfiguring, particularly
for a female patient.
Patients who require concomitant cardiac surgery such as coronary artery bypass grafting (CABG),
mitral/tricuspid valve surgery, ascending aortic replacement, or atrial fibrillation (AF) ablation
procedures are not ideal candidates for MIAVR. In principle, the cardiac operation itself should not be
compromised in order to pursue a minimally invasive approach, and a complex, but complete, operation
may be better suited through a full sternotomy. Nevertheless, limited CABG to the right coronary artery,
double valve surgery, AVR with ascending aortic replacement, and AVR with AF ablation procedures
have been successfully performed with a minimally invasive approach. Moreover, a hybrid approach
may be considered, in particular for patients requiring coronary revascularization. Coronary artery
stenting may be performed before or after MIAVR, depending on clinical presentation.
Preoperative planning should include imaging to determine the appropriate location for the UHS or ART
incision and to evaluate the peripheral vasculature if peripheral cannulation is planned. Peripheral
arterial cannulation may be beneficial in ART where direct aortic cannulation is remote from the
incision. It is important for the surgeon to have a plan for myocardial protection, which may include
adjunctive techniques in percutaneous cardioplegia.
Preoperative Work-Up
Preoperative evaluation for MIAVR requires careful attention to several pre-existing conditions:
Peripheral vascular disease (PVD), chronic obstructive pulmonary disease (COPD), a history of chest
wall irradiation or deformity, and previous cardiac surgery.
Figure 6.1 CT evaluation for the anterior right thoracotomy approach. Axial view demonstrating an appropriate
candidate for anterior right thoracotomy access for MIAVR. At least half of the ascending aorta is to the right of a line
drawn from the right sternal edge through the aorta.
In patients with PVD, the risk of stroke or systemic embolization is significantly elevated with
retrograde arterial perfusion. Computed tomography (CT) angiography of the chest, abdomen, and
pelvis should be done routinely if retrograde arterial perfusion is planned. It is important to assess
severity, location, and nature of atherosclerosis. Plaque that is smooth and calcified poses less of a
danger than soft or irregular lesions. Consideration must also be taken of the size and tortuosity of the
iliofemoral vessels when selecting the appropriate arterial cannula. Moreover, patients who undergo
preoperative coronary catheterization are at risk for iatrogenic dissection of the iliac artery during
femoral access. Occult dissection is usually confined to a tortuous segment as it emerges from the
pelvis. However, if unrecognized, acute dissection into the aorta can be induced by retrograde arterial
perfusion. To avoid this complication, CT angiography should be performed after cardiac catheterization
when femoral artery cannulation is anticipated.
The chest deformity seen in severe COPD may alter the anatomic relationship between the chest wall
and aortic valve. CT allows visualization of the anatomic structures within the chest and provides crucial
information about their spatial relationships. CT is also useful for evaluation of the pleural space and the
extent of lung disease. It is important to determine the distance between the posterior sternal table and
the right ventricle, preoperatively, in patients with previous cardiac surgery or chest wall irradiation.
This can be achieved with noncontrast chest CT. In patients with previous CABG, patent internal
mammary artery grafts crossing the midline are particularly hazardous. When planning ART, a careful
history must be taken of recurrent pneumonia, pneumothorax, and right lung resection, as these may be
associated with dense pleural adhesions.
Finally, the added benefit of preoperative CT imaging also includes preoperative planning of the
incision for UHS with direct ascending aortic cannulation, to evaluate the severity and distribution of
aortic calcification. This information is helpful in the formulation of cannulation and cross-clamp
strategy. In bicuspid aortic valve disease, CT may be used to measure the aortic root and ascending aorta
to determine the presence of aortic aneurysm that will alter the approach. Chest CT is also helpful in
determining which patients are best candidates for ART. A vertical line is drawn from the right sternal
border through the ascending aorta in the axial CT view ( Fig. 6.1). If more than one-half of the
ascending aorta is to the right of this line, ART is appropriate. From the CT, the preferred intercostal
space for both ART and UHS can be determined. The ideal interspace is marked by the tip of the right
atrial appendage.
Preparation for Cannulation and Cardioplegia

The surgeon must devise a plan for cannulation and administration of cardioplegia. Peripheral
cannulation should be considered for reoperative MIAVR given the risk of adhesions and the need to
quickly place the patient on bypass if uncontrolled hemorrhage occurs. Cannulation options include the
right axillary artery and the common femoral artery. At the very least, a wire should be placed in the
common femoral artery, prior to sternotomy. UHS should provide ample exposure for placement of an
arterial cannula in the ascending aorta. Although venous cannulation through the UHS incision is easily
accomplished, percutaneous femoral venous cannulation is preferred to maximize exposure through the
small incision. Aortic cannulation via ART, however, can be challenging and the procedure is more
easily performed using open cannulation of the common femoral artery and vein.
Cardioplegia may be given using antegrade or retrograde delivery. Antegrade cardioplegia is given
initially through the aortic root and can be subsequently delivered directly into the right and left main
coronary ostia after aortotomy. Alternatively, retrograde cardioplegia may be given after the initial
antegrade dose. For both UHS and ART, the retrograde catheter can be placed directly through the right
atrium and directed into the coronary sinus under TEE guidance. To maximize exposure and minimize
cannula clutter, a percutaneous transjugular coronary sinus catheter may be placed under TEE and
fluoroscopic guidance by an experienced cardiac anesthesiologist, prior to incision. The decision to use
a transjugular coronary sinus catheter must be appropriately communicated to the anesthesiologist prior
to the operation. With an experienced team, catheter placement should not add more than 15 minutes to
the total operating room time.
SURGERY
Positioning
For both UHS and ART, the patient is placed in the supine position with arms tucked at the sides.
External defibrillator pads are placed on the patient. The surgeon should confirm with the anesthesia
team that the pulse oximeter and peripheral arterial and venous lines are functional. The incision should
be marked on the skin. The patient is then prepped and draped to include the chest incision and the
groins.
Intraoperative Monitoring, Lines, and Ventilation

Intraoperative TEE is used routinely in MIAVR. A PA catheter may be indicated depending on the
patient’s risk factors. If peripheral arterial cannulation is planned, limb perfusion can be monitored using
pulse oximetry of the lower extremities for femoral cannulation or with an ipsilateral radial arterial line
during axillary cannulation. To reduce the number of cannulae in the operative field, the right atrial
venous cannula should be placed percutaneously through the common femoral vein. In addition, both
the retrograde cardioplegia catheter and PA vent may be placed percutaneously through the jugular vein.
An experienced cardiac anesthesiologist usually performs this procedure, which requires TEE imaging
supplemented with portable fluoroscopy.
A single-lumen endotracheal tube is standard for both ART and UHS exposures. The right lung may
be retracted posteriorly in ART to achieve optimal visualization without single-lung ventilation. Due to
the smaller caliber of peripheral cannulae, vacuum- or kinetic-assisted venous drainage is used to
facilitate emptying of the heart for peripheral CPB.
Technique
Upper Hemisternotomy Approach
For surgeons who are not yet experienced in MIAVR, the J-shaped UHS is the recommended initial
approach. UHS has the advantage of not requiring any specialized equipment. It can be applied to both
primary and reoperative surgery, with either central or peripheral CPB. Precise incision placement is
assisted by preoperative chest CT, which identifies the aortic valve relative to the surface anatomy of the
bony thorax. A 5 to 8 cm vertical skin incision is made just caudal to the sternal angle of Louis (Fig.
6.2A). Subcutaneous tissue is dissected up to the sternal notch superiorly and down to the intercostal
space inferiorly, without requiring extension of the skin incision. The J-shaped hemisternotomy is
mapped out along the center of the sternum into the right third or fourth interspace ( Fig. 6.2B),
depending on preoperative imaging, and is scored using electrocautery. For patients without a
preoperative chest CT, and for surgeons new to MIAVR, the fourth interspace should be used to
optimize exposure.
Figure 6.2 Upper hemisternotomy incision. A: Marking for skin incision. B: J-shaped upper hemisternotomy in the
third or fourth right intercostal space. C: Upper hemisternotomy incision exposure with a low-profile retractor and
narrow blades.
A sternal saw is used to make the hemisternotomy and the right internal thoracic artery is spared. A
rigid retractor with narrow blades is inserted. The pericardium is opened vertically with electrocautery
and pericardial stay sutures are placed to expose the aorta, right atrium, and inferior vena cava (Fig.
6.2C). After removing the retractor, the pericardial sutures are then aggressively pulled up to the skin
edges, enhancing exposure by displacing the aorta and heart anteriorly and cranially. Occasionally,
impaired venous return from the inferior vena cava can kink during this maneuver, causing hypotension.
This scenario is easily managed by simply reinserting the sternal retractor and infusing intravenous
fluid, as needed. A separate stab incision is made for a catheter to insufflate the field with carbon
dioxide, and can later be used for chest tube insertion.
The UHS exposure allows for conventional central aortic and right atrial cannulation (Fig. 6.3). If
necessary, intraoperative TEE or epiaortic ultrasound may be used to identify a site on the aorta free of
significant atheromatous disease. After systemic heparinization, the ascending aorta is cannulated
distally to provide ample working space. Smaller aortic cannulae may be used, according to surgeon
preference. Venous cannulation is performed through the right atrium in standard fashion. To further
reduce the number of cannulae in the surgical field, percutaneous femoral venous cannulation may also
be considered. For percutaneous access, the right common femoral vein is punctured with an 18-gauge
needle and a standard, soft J-tipped wire is advanced into the superior vena cava under TEE guidance.
Imaging with TEE is important to avoid placing the cannula into the right atrial appendage or a patent
foramen ovale. After serial dilatation of the soft tissue tract and vein, a multi-sidehole venous cannula is
advanced with the tip positioned 2 cm into the superior vena cava, again confirmed by TEE. Any
difficulty in advancing the venous cannulae through the iliac veins in the pelvis can be overcome with a
stiff wire (technique described below). Venous drainage is facilitated by vacuum or kinetic assistance.
Figure 6.3 Upper hemisternotomy exposure for aortic valve replacement. A: UHS exposure demonstrating
placement of aortic and antegrade cardioplegia cannulae and cross-clamp. Venous cannula is placed femorally (not
shown). Retrograde cannula may be placed directly, percutaneously, or omitted. B: Aortotomy and exposure of
aortic valve.
Both antegrade and retrograde cardioplegia may be delivered during UHS, similar to conventional
AVR. The antegrade cannula may be removed after the initial delivery of cardioplegia to improve
exposure of the aortic root. The suture is kept in place to allow replacement of the antegrade cannula
after aortotomy closure. The retrograde cannula is placed directly under TEE guidance, as it is not
possible to palpate the coronary sinus through the UHS incision. Decompression of the left ventricle is
achieved by cardiotomy suction through the aortic valve or, indirectly, with a percutaneously placed PA
vent. The heart should be visually inspected to ensure adequate decompression once CPB is initiated.
Malpositioned cannulae will result in poor drainage and should be adjusted for complete emptying of the
heart. Often, simple rotation of the cannula results in adequate venous drainage. Once on bypass, the
aorta is occluded with a standard ACC. A transverse aortotomy is placed slightly below the fat line on
the aorta to facilitate closure and visualization of hemostasis at the end of the operation. Retraction
sutures are placed at the edges of the aortotomy, and at each commissure, to further elevate the aortic
valve within the operative field.
The valve is excised in standard fashion and the annulus is decalcified, as needed. The annulus is
sized for valve placement and may be formally enlarged to accommodate the appropriate size valve. The
aortic valve annulus sutures are placed, which may be facilitated by long-shafted instruments. An
auto-knotting device may be used to secure the sutures once the valve is seated. The aortotomy is closed
in the usual fashion. Temporary epicardial wires are affixed to the decompressed right ventricle, before
the ACC is removed, and passed through the skin subcostally. Deairing demands meticulous attention to
detail and TEE monitoring to ensure completion. The heart is partially filled with blood and the lungs
are gently ventilated before aortotomy closure to encourage egress of air. Suction is applied to the aortic
root vent before the ACC is removed. If necessary, the heart is defibrillated using the externally placed
pads. Prosthetic valve function and cardiac performance are assessed by TEE. Surgical hemostasis is
achieved and the pericardium is closed over a single pericardial drain. The sternum is reapproximated
using steel cerclage wires. Intercostal nerve block using a long-acting local anesthetic, such as
bupivacaine, is injected into the intercostal nerve bundle. The wound is closed in customary fashion and
a temporary pain pump can be used to minimize postoperative pain.
Anterior Right Thoracotomy Approach

The ART approach avoids sternotomy and requires a limited horizontal skin incision away from the
midline, which can be easily hidden under clothing. The drawbacks of this technique are a smaller
operative view and an aortic valve that sits deeper within the operative field. Minimizing cannula
placement within the incision and strategic placement of pericardial retraction sutures enhances
exposure. Peripheral cannulation is performed before skin incision. If both iliofemoral vessels are
adequate, the right side is preferred. On the left, the iliac artery may compress the iliac vein as it crosses
the pelvic brim. However, iliofemoral size, calcification, and tortuosity on the preoperative CT
angiogram should be the major factors guiding placement. Slight hyperextension of the hips facilitates
safe advancement of the cannula across the pelvis. A small (4 cm) oblique incision is made over the
common femoral vessels, which, in most cases, corresponds to an area just above the groin crease. In
obese patients, the groin crease is shifted caudally, and the incision is made slightly higher, at the level
of the inguinal ligament. Both common femoral artery and vein are exposed anteriorly (circumferential
dissection is not required and limited dissection reduces the risk of postoperative lymphocele), and 4-0
polypropylene purse-string sutures are placed. An 18-gauge needle is used to introduce a soft, J-tipped
guidewire into the common femoral vein. The guidewire is advanced under TEE guidance through the
common femoral vein, into the superior vena cava, avoiding the right atrial appendage, a patent foramen
ovale, tricuspid valve, and coronary sinus. A multi-sidehole femoral venous cannula is then passed over
the wire until the tip is 2 cm within the superior vena cava. A stiffer wire may be indicated if there is
difficulty passing the cannula. Wire exchange is accomplished by first placing a standard 6-Fr sheath
followed by an exchange catheter. The size of the wire and its compatibility with the catheter must be
noted. The soft wire is then exchanged for a stiff wire at least 260 cm in length to accommodate the long
venous cannula. Using Seldinger technique, the common femoral artery is cannulated. The cannula tip is
positioned within the external iliac artery, while avoiding obstruction of the internal iliac artery. To
allow antegrade perfusion of the distal limb, no tourniquets or clamps are placed on the femoral artery.
If there is any concern for limb ischemia, a 14-gauge catheter may be inserted into the femoral artery
distally and connected to the arterial cannula. For retrograde cardioplegia, a percutaneous coronary sinus
catheter may be introduced through the right internal jugular vein, and placed under TEE or fluoroscopic
guidance. A percutaneous PA vent may also be inserted through the right jugular vein ( Fig. 6.4).
Figure 6.4 Percutaneous venous cannula, transjugular coronary sinus catheter, and pulmonary artery vent. A
well-positioned femoral venous catheter is shown terminating in the superior vena cava. A transjugular placement of
a retrograde cardioplegia catheter in the coronary sinus and a vent in the pulmonary artery may also be used to
minimize clutter in the operating field.
Figure 6.5 Anterior right thoracotomy incision and surgical exposure. A: Skin incision in the right third intercostal
space. B: Surgical exposure with a soft-tissue retractor and low-profile rigid retractor with narrow blades. C: ART
incision cannula placement. The antegrade catheter is placed through the incision. A low-profile aortic clamp is
placed through a separate stab incision. Arterial and venous cannulae are placed peripherally; a retrograde cannula
and a PA catheter are placed percutaneously.
A 4 to 6 cm transverse skin incision is made over the right intercostal space, near the sternal border (
Fig. 6.5A). The exact location of the incision may be modified based on the preoperative chest CT. The
right internal thoracic vessels are usually ligated and divided. The third or fourth rib can be dislocated
from the sternum to enhance visualization of the right atrial appendage. A soft tissue retractor is inserted
into the wound followed by a rigid retractor with narrow blades (Fig. 6.5B). Pericardial fat is excised
while taking care to avoid the phrenic nerve. The pericardium is incised 3 to 4 cm anterior and parallel
to the nerve. The pericardiotomy is extended inferiorly toward the diaphragm and superiorly to the
pericardial reflection. Retraction sutures are placed at the edges of the pericardium and passed through
the chest wall, away from the incision (Fig. 6.5C). The operative field is insufflated with carbon dioxide
gas through a separate stab incision, similar to UHS. An antegrade cardioplegia needle is inserted
directly into the ascending aorta, and a low-profile ACC (e.g., Chitwood clamp) is placed through a
separate stab incision. Antegrade cardioplegia is administered in standard fashion.
Technical details of aortotomy, prosthetic valve implantation, and aortotomy closure are similar to
UHS except for several considerations. Valve sutures can be first placed at the right coronary cusp and
retracted to facilitate exposure. Knot pushers or an auto-knotting device may be necessary if the valve is
deep within the chest. As with the UHS approach, temporary epicardial pacing wires are placed before
the ACC is removed.
Once weaned from bypass, the femoral cannulae are removed and adequate distal limb perfusion is
confirmed. A small chest drainage tube is inserted in the right pleural space through a separate incision.
The pericardium is left open and the disarticulated rib is reattached to the sternum using a
figure-of-eight, 2-0 nonabsorbable, braided suture. The ribs are reapproximated to avoid lung herniation.
A long-acting local anesthetic is injected into the intercostal nerve bundle. The chest incision is closed
and the groin is approximated in layers to compress lymphatics and eliminate dead space. In obese
patients, drain placement may help reduce the risk of hematoma, seroma, and subsequent infection. If, at
any time during the operation, the exposure is inadequate, conversion to full sternotomy should be
performed without hesitation. Full exposure will allow safe completion of the valve replacement with an
approach familiar to the surgeon.
Postoperative care of patients undergoing MIAVR requires a fundamental change in management
philosophy. Simply imposing the clinical pathway for conventional AVR fails to leverage advances in
best practices, and misses the opportunity for improved patient outcomes. As with conventional AVR,
patients are managed postoperatively in a cardiac intensive care unit (ICU). They are immediately
weaned from ventilator support and most patients are extubated within a few hours of surgery. Invasive
line monitoring is utilized to guide extubation, fluid resuscitation, and weaning of any inotropic support.
MIAVR patients should be able to be transferred from the ICU to the telemetry unit on the first
postoperative day, with all invasive line monitoring discontinued. The single mediastinal chest tube is
removed when output decreases to <100 mL per 8 hours.
Due to better preservation of chest wall integrity, MIAVR is often associated with a faster return to
work: 2 to 4 weeks for ART and 3 to 4 weeks for UHS. Conduct in the operating room has a significant
effect on postoperative recovery. Early extubation is facilitated by moderation of intraoperative doses of
narcotics, sedatives, and muscle relaxants. Complete, or near-complete, rewarming of the patient is
achieved while in the operating room. After ART, incision pain peaks within the first 12 to 24 hours
and, with limited rib retraction, subsides rapidly. Incisional pain in appropriately selected patients (e.g.,
nonelderly, normal renal function) may be ameliorated with judicious use of intravenous nonsteroidal
anti-inflammatory agents. In general, the use of parenteral narcotics is limited to the first 48 to 72 hours
and patient-controlled analgesic pumps are rarely indicated. In the event of significant bleeding or
tamponade, the chest should be re-explored through the UHS or ART incision in the operating room. A
sternal saw and wire cutters must be readily available in the cardiac ICU should emergency re-entry be
required. The patient should be mobilized to promote complete drainage from the costophrenic recesses
before chest tube removal. Stable patients are aggressively diuresed. The threshold to perform
thoracentesis or tube thoracostomy, for a residual pleural fluid collection, should be low.
The postoperative management considerations for MIAVR generally mirror conventional AVR,
though in expedited fashion. Blood glucose is monitored and euglycemia is maintained with insulin
infusion in the ICU setting. Indwelling urinary catheters and prophylactic antibiotics should be
discontinued appropriately. AF is treated as per algorithm. All invasive lines are removed, and the
patient is mobilized, ideally, on postoperative day one. Transfer from the cardiac ICU to the telemetry
unit usually occurs on the first postoperative day. In general, patients are discharged from the hospital
between postoperative days 3 and 5. All patients are contacted within 72 hours of discharge to assess
their overall recovery. Patients follow up with their outpatient cardiologists at 2 weeks and with their
surgeons between 2 and 4 weeks post discharge. After ART, given the absence of a midline incision, it
is especially important to send the operative report to the referring cardiologist and primary care
physician as a documentation of aortic valve surgery. For MIAVR, standard sternal wound precautions
are relaxed; patients may resume driving once they have ceased taking oral narcotics. Upper extremity
range-of-motion precautions are eased and heavy lifting is titrated to pain tolerance. A period of 3 weeks
of weight restriction is recommended if the exposure requires rib disarticulation. Otherwise, no physical
restrictions apply upon hospital discharge.
COMPLICATIONS
Postoperative complications are similar to those after conventional AVR. However, special precautions
must be taken to manage certain complications and avoid catastrophe after MIAVR.
Postoperative bleeding: The risk of postoperative bleeding after MIAVR is less than that after
full sternotomy. However, attention to hemostasis through a mini-incision is mandatory and a
low threshold for re-exploration is prudent. Sources of bleeding include the sternotomy incision,
wire closure sites, and aortotomy and cannulation sites. In the hemodynamically stable patient
with elevated mediastinal drainage, re-exploration can be safely performed in the operating
room and through the same UHS or ART incision. Early re-exploration for mediastinal bleeding
should be considered in order to avoid the possibility of cardiac tamponade.
Cardiac tamponade: Special precautions are necessary to avoid and treat cardiac tamponade. A
pericardial chest tube is placed for postoperative drainage; however, it is possible for the chest
tube to become clotted and for blood to accumulate rapidly around the heart. The patient’s
hemodynamics must be monitored closely in the immediate postoperative period to assess for
tamponade physiology, particularly if there is any concern that the chest tube is not draining
properly. A chest tube with a large amount of bloody output that suddenly stops should be
suspicious for clot formation. Finally, a sternal saw and wire cutters should be readily available
in the cardiac ICU should emergent re-entry be required. Exposure may not be sufficient
through the same UHS or ART incision, and the surgeon should be prepared to proceed directly
to full sternotomy using a battery-powered reciprocating sternal saw.
Heart block: Postoperative edema may cause temporary heart block due to valve placement near
the atrioventricular conduction system. The patient may require temporary pacing, which makes
the intraoperative placement of functioning ventricular pacing wires essential. This step should
not be omitted due to a minimally invasive approach. As mentioned previously, exposure for
placement of epicardial wires is greatly facilitated by placing them while on-pump or with the
heart arrested. In a small percentage of cases, the patient will go on to have permanent heart
block and will require permanent pacemaker insertion.
RESULTS
Outcomes for MIAVR are similar to those for conventional, full-sternotomy AVR. Minimally invasive
approaches are safe with no increased risk of death or other major complications, despite longer CPB
and ACC times. Some studies have demonstrated a decrease in hospital and ICU length of stay, shorter
ventilation times, and decreased blood loss with MIAVR. Incidence of postoperative complications,
such as AF, stroke, and sternal complications, show no difference compared to conventional AVR.
Conversion rate from mini to full sternotomy has been reported at 3%.
Four published meta-analyses compare MIAVR to conventional, full-sternotomy AVR. Three of these
recent publications analyze 30-day mortality and demonstrate equivalent, if not improved, safety for
MIAVR, despite longer CPB and ACC times (Table 6.1). Important differences in secondary outcomes
include decreased blood transfusions, shorter ventilation time, reduced ICU and hospital length of stay,
and less renal failure, in favor of MIAVR (Table 6.2). Although definitive clinical evidence is lacking, it
is generally accepted that decreased pain, faster recovery, and improved cosmesis are other secondary
benefits of MIAVR.
TABLE 6.1 Perioperative Mortality, Cardiopulmonary Bypass, and Aortic Cross-Clamp Times for MIAVR
Compared to Full-Sternotomy AVR
TABLE 6.2 Postoperative Outcomes for MIAVR vs. Full-Sternotomy AVR
CONCLUSIONS
MIAVR is a safe alternative to conventional, full-sternotomy AVR. Since its first description in 1993,
increasing evidence of reduced postoperative complications has emerged. There may also be benefits of
improved cosmesis and faster recovery. The most preferred approaches for MIAVR are UHS and ART.
CT imaging is key for preoperative planning. Intraoperatively, the surgeon must be adept at peripheral
cannulation. Specialized operative equipment facilitates MIAVR. The management of postoperative
bleeding and tamponade require special attention. Any patient requiring isolated AVR should be
considered a candidate for MIAVR.

Brown ML, McKellar SH, Sundt TM, et al. Ministernotomy versus conventional sternotomy for aortic valve replacement: A
systemic review and meta-analysis. J Thorac Cardiovasc Surg. 2009;137:670–679.
Cosgrove DL, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg. 1996;62:596–597.
Khoshbin E, Prayaga S, Kinsella J, et al. Mini-sternotomy for aortic valve replacement reduces the length of stay in the cardiac
intensive care unit: meta-analysis of randomised controlled trials. BMJ Open. 2011;1:e000266.
Malaisrie SC, Barnhart GR, Farivar RS, et al. Current era minimally invasive aortic valve replacement: Techniques and practice.
J Thorac Cardiovasc Surg. 2014;147:6–14.
Murtuza B, Pepper JR, Stanbridge RD, et al. Minimal access aortic valve replacement: Is it worth it? Ann Thorac Surg. 2008;85
:1121–1131.
Phan K, Xie A, Di Eusanio M, et al. A meta-analysis of minimally invasive versus conventional sternotomy for aortic valve
replacement. Ann Thorac Surg. 2014;98(4):1499–1511. Advance online publication. doi: http://dx.doi.org/10.1016/j.athoracsur
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Rao PN, Kumar AS. Aortic valve replacement through right thoracotomy. Texas Heart Inst J. 1993;20:307–308.

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Part I

Primary Aortic Valve Surgery

TABLE 1.1 Stages of Valvular Aortic Stenosis

Figure 1.8 Patch enlargement of the aortotomy when strut is protruding.

Recommended References and Readings

Aortic Valve Assessment

Lower Extremity Assessment

Alternative Access Considerations

Figure 2.4 Axillary exposure for subclavian TAVR delivery.

Less Common Routes

Less Common Complications

Recommended References and Readings

Terminology and Definition

Figure 3.4 Commissurotomy.

Figure 3.7 Reinforcement of the free margin of a prolapsing leaflet.

3. Patch plasty and patch augmentation

Figure 3.9 Subcommissural annuloplasty.

Bicuspid Aortic Valves

TABLE 3.2 Classification of Bicuspid Aortic Valves

Recommended References and Readings

Bypass Setup and Pressure Measurement

Septal Muscle Excision

Recommended References and Readings

Positioning and Access for Cardiopulmonary Bypass

Recommended References and Readings

Preparation for Cannulation and Cardioplegia

Intraoperative Monitoring, Lines, and Ventilation

Anterior Right Thoracotomy Approach

TABLE 6.2 Postoperative Outcomes for MIAVR vs. Full-Sternotomy AVR

Recommended References and Readings

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