“Sleeve” Sinus Valsalva Repair in Patients with Acute Type A Aortic
Dissection
Laichun Song1, M.D., Yang Gao2,
M.D., Ming Xu1, M.D., Bo Wang1, M.D.
Xiaoyong Li1, M.D. Xiao Wang1, M.D.
1 Department of Cardiac Surgery, Asia heart hospital, Wuhan, P.R. China,
Affiliated Wuhan University of Science and Technology, Wuhan, P.R.
China.
2 Department of Anesthesiology, Asia heart hospital, Wuhan, P.R. China.
Corresponding Author: Xiao Wang, M.D. Department of Cardiac Surgery,
Asia heart hospital, Wuhan, P.R. China.
Address: No.753 Jinghan Road, Hankou District, Wuhan, P.R. China, 430022
E-mail:doctorslc@hotmail.com.
Laichun Song, Yang Gao and Ming Xu have the same contribution to the
article.
Manuscript type: Original Article
Funding Statement: This work was supported by Health and Family Planning
Commission of Wuhan municipality scientific research project
(WJ2018H0041, WJ2018H0047)
Conflict of Interest (COI) statement: There are no conflicts of interest
to disclose. All the data was available.
“Sleeve” Sinus Valsalva Repair
in Patients with Acute Type A Aortic Dissection
Running title: Aortic root reconstruction in Acute Type A Aortic
Dissection
Abstract.
Purpose.
The optimal surgical strategy of aortic root in acute type A aortic
dissection (ATAAD) is controversial. The aim of this study was to
evaluate the feasibility and safety of
“Sleeve” sinus Valsalva repair
for AAD limited to the non-coronary sinus or partial left and right
coronary sinus without involvement coronary artery ostia.
Methods:
From Sep 2016 to Mar 2019, 20 patients with AAD involving non-coronary
sinus or partial left and right coronary sinus Valsalva underwent
“Sleeve” sinus Valsalva repair . Multi‑slice spiral computed
tomography angiography (MSCT) and three‑dimensional reconstruction were
routinely performed in all patients to assess the maximal diameters of
each segment of the aorta.
Results.
There was no early death in hospital and one death during the 30-day
postoperative period. Re-thoracotomy due to bleeding was necessary in
only 1 patient and no bleeding was related to the proximal anastomosis.
The post-operative drainage was 390.5±229.3mL. During the following-up,
the echocardiography showed the normal sinus of Valsalva and aortic
valvular function. The computed tomography angiography showed normal
aortic root without endovascular leak or dissection around the sinus of
Valsalva. All patients were free from reoperation.
Conclusions. “Sleeve” sinus Valsalva repair with Dacron patch for
aortic dissection limited to the non-coronary sinus or partial left and
right coronary sinus without involvement coronary artery ostia was
technically feasible and safe.
Keywords: Acute type A aortic dissection; Aortic Root Reconstruction;
Aortic Valve
Introduction
Acute type A aortic dissection (ATAAD) is a life-threatening disease
with contemporary perioperative morality rates of 13% to 17%
[1,2]. The dissection flap in
the ascending aorta often extends into the sinus segment, resulting in
aortic regurgitation (AI) [3]. The aortic root anatomy including
aortic valve and sinus segment is normal in most patients before
experiencing ATAAD. In addition, the aortic apparatus including the
aortic annulus and leaflets are not involved in most cases, which makes
the aortic root reconstruction possible to preserve the aortic leaflets
and function. Thus, various surgical techniques including the external,
internal, or intramural reinforcement with prosthetic, biologic, or
autologous materials, have been applied to reconstruct the aortic root
to spare the aortic leaflets [4-6]. However, there remain
significant complications during the long-term follow-up, including
progressive dilatation of the preserved aortic root, formation of
proximal false aneurysm, and progression of aortic regurgitation (AR)
[7-10]. To prevent these events, total aortic root reconstruction or
replacement including David, Yacoub and Bentall procedure may
beperfomed, which could be burdened by the complex surgical manipulation
and injury risk of coronary artery [11-12].
The technique of “Sleeve” sinus Valsalva repair has been applied in
our center for several years with excellent clinical results. The
purpose of this study was to introduce the novel technique of “Sleeve”
sinus Valsalva repair to preserve the aortic valve and to evaluate the
feasibility and safety of the approach for proximal reapproximation.
Materials and Methods
Patient Selection
This study was approved by the Institutional Review Board of Wuhan Asia
Heart Hospital and was in compliance with the Health Insurance
Portability and Accountability Act regulations and the Declaration of
Helsinki. The institutional review board waived the need for individual
patient consent.
From September 2016 through March 2019, 20 consecutive patients with
acute type A aortic dissection (ATAAD) underwent “Sleeve” sinus
Valsalva repair combined with total arch replacement and stented
elephant trunk implantation in our center. Multi‑slice spiral computed
tomography angiography (MSCT) and three‑dimensional reconstruction were
routinely performed in all patients to assess the maximal diameters of
each segment of the aorta, including the aortic root. Transthoracic
echocardiography (TTE) and transesophageal echocardiography was
performed in all patients to evaluate aortic regurgitation and other
valvular dysfunction, to identify the location of intimal tears and the
presence of coronary involvement. The location of intimal tears and
extent of dissection in the aortic root was confirmed with
intraoperative findings. The technique of “Sleeve” sinus Valsalva
repair is performed in the patients with the diameter of aortic sinus
<45 mm, AI without diseased leaflets, dissection limited
in the non-coronary sinus or
partial left and right coronary sinuses without involvement coronary
artery ostia. Coronary artery bypass grafting (CABG) is necessary in
patients with coronary artery involvement
Surgical techniques
All the patients underwent surgical intervention within 48 hours of
clinical onset by the same surgeon. All the procedures were performed
under general anesthesia and via a standard median sternotomy. CPB was
established by cannulating in the femoral artery and a dual-stage
atriocaval cannula used in the right atrium. Cerebral protection was
established through the innominate artery for antegrade cerebral
perfusion or the superior vena cava for retrograde cerebral perfusion.
The innominate artery, left common carotid artery, and the LSA were
dissected and exposed. Myocardial protection instituted with antegrade
cold Del-Nido cardioplegia delivered antegrade. During the procedure, if
there was no intimal tear in the arch, only the ascending aorta and/or
hemiarch replacement was performed; if there was tear in the arch and
descending aorta, the ascending aorta and total arch replacement
combined with stented elephant trunk implantation under direct
visualization was performed i. During cooling, aortic root procedures
were performed according to the extent of aortic dissection and
pathologic status of the aortic valve.
The ascending aorta was transected circumferentially at approximately 5
mm above the STJ. All the thrombus in the dissected aortic layers were
wiped out without destroying both the intima and adventitia. A tailored
Dacron patch was inserted into the dissected layers and a mattress
stitch was used to fix the patch at the bottle of the sinus. Two 4mm
Dacron strips were placed inside and outside of the aorta and the new
five-layers root was sutured with 3/0 prolene continuous stitches
(“Z”shape suture line, Fig 1 and 2). To prevent interference of the
coronary flow, the inner felt was frequently trimmed and secured at each
orifice level of the coronary artery. Then the reconstructed root was
anastomosed with artificial vessel. The artificial vessel was reversed
about 1cm and anastomosed with the reconstructed root. Then, the
reversed artificial vessel was pulled and anastomosed with the Dacron
strip of the new proximal aorta
(“Sleeve “technique, Fig 2).
However, this technique is not recommended if any of the following
conditions are present: Marfan syndrome, the dissection involving 2 or
more sinuses of Valsalva, a root aneurysm (>4.5 cm), and
known connective tissue disorders.
Follow-up
The durability of the root repair was assessed by follow-up
transthoracic echocardiography and computed tomographic angiography 6
and 12 months postoperatively and annually thereafter.
Data Management and Statistical Analysis
The data were managed and analyzed by using SPSS19.0. Data are expressed
as mean±standard deviation for continuous variables and as median and
range for categoric variables.
Results
Demographic and Clinical Characteristics
The mean age was 61.65±9.54 years (ranges from 49 to 80 years). Among
them, 13 patients were male and 7 patients were female. According to the
echocardiography, the LVEF ranged from 40-60% (mean 50.97±3.41), and
aortic regurgitation and mitral regurgitation were observed in 15 cases
(75%) and 2 cases (10%), respectively. 4(20%) patients had impaired
renal function.
Per-operative profiles
All the patients underwent “Sleeve “sinus Valsalva repair to preserve
the aortic valve and no patient needed to perform the Bentall procedure.
Two patients (10%) who had coronary artery malperfusion underwent CABG
with saphenous vein graft. The most frequency of involving coronary
artery was the right coronary artery. 2 patients performed mitral
annuloplasty with a strip of autogenous pericardium for the normal
leaflets without anatomical dysfunction. The cardiopulmonary bypass time
was 207.35±45.89 minutes, cross-clamp time was 133.75±42.15 minutes, and
circulatory arrest time was 23.28±5.56 minutes.
There was no patient death in hospital. Re-sternotomy due to bleeding
was necessary in only 1 patient and no bleeding was related to the
proximal anastomosis of the conduit. The post-operative drainage was
few( 390.5±229.3mL). The mean intubation time was 8.03±3.3 hours and ICU
stay was 2.69±0.13 days. No stroke and persistent neurologic dysfunction
occurred. Delirium was observed in one patient and recovered
5th day after the procedure.
Results from Follow-up
All patient follow-up was confirmed by a schedule of recent visits or by
telephone, and follow-up was complete in all patients. All patients were
followed up every three months for the first year with echocardiography
to detect the aortic root. Computed tomographic angiography was
scheduled for each patient before discharge, every 6 months for the
first year, and annually thereafter. The echocardiography showed the
normal sinus of Valsalva and aortic valvular function. The computed
tomography angiography showed normal aortic root without endovascular
leak or dissection around the sinus of Valsalva (Fig 3). All patients
were free from reoperation.
Discussion
Spontaneous acute type A aortic dissection is a rare and
life‐threatening condition. Surgical intervention is the optimal
strategy for these patients, in spite it still is associated with high
mortality and morbidity for the complex surgical manipulations. Complete
or valve sparing aortic root replacement has been the most common
procedure for this disease. However, there is no clear consensus about
the surgical strategy for patients with the dissection limiting to the
non or right coronary sinus. Because the other sinus of the Valsalva,
aortic cusps, and sinotubular junction may be fairly intact in these
patients, which makes aortic root reconstruction possible to preserve
the aortic valve.
In 1995, David [11] firstly performed the partial aortic root repair
to correct the dilated sinotubular junctions and dissected noncoronary
sinus in abnormal or mild dilated aortic sinuses. Subsequently, various
modifications to spare the aortic valve have been reported in patients
with ATAAD [4,5,12-14]. Komiya et al[12] reported that the
modification of partial aortic root remodeling was performed by fixing a
U‐shaped Dacron patch in the sinus. In their study, when the dissection
involved right coronary sinus, the ostium of right coronary artery was
reimplanted to the patch. Tang et al [4] reported 151 patients with
acute type A aortic dissection underwent modified sandwich repair of
aortic root with excellent long-term results. The modified sandwich
technique using Teflon felt can be successfully performed in most
patients with acute type A aortic dissection and is associated with low
in-hospital mortality and low root reoperation rates in the long run.
However, these techniques have some potential risk for dilatation of
aortic root, aortic valve insufficiency, and pseudoaneurysm. Thus, to
reduce the perioperative mortality rates and improve the long-term
outcomes, an appropriate proximal aortic root procedure should be
performed in selected patients with ATAAD.
The principles for successful aortic root reconstruction are thoroughly
elimination of dissection in the sinus of Valsalva, no aortic root
bleeding during or after the procedure, and prevention of aortic
regurgitation caused by aortic root dilatation and residual aortic sinus
dissection or pseudoaneurysm during the long run [15,16]. Many
surgical techniques with or without polytetrafluoroethylene felt
bolsters or biological glue can be used to reconstruct the aortic to
preserve aortic valve. However, the incidence of bleeding after the
procedure were very high, which need re-exploration and reoperation
should be performed for aortic pseudoaneurysm during the following-up
[16]. Fortunately, in our series, re-sternotomy due to bleeding was
necessary in only 1 patient and no bleeding was related to the proximal
anastomosis. Because placing theDacron strips external and internal to
the sinus of Valsalva wall and “Z”shape suture line were very
effective at preventing tears and bleeding from the needle holes in the
dissected tissue. Furthermore, “Sleeve “technique not only reinforced
the anastomosed, but also reduced the tension of anastomosis when the
aorta contracting and relaxing, which may reduce the bleeding and
residual dissection in the sinus of Valsalva. In addition, the cardiac
surgeon could palpate the reconstructed sinus of Valsalva wall to
estimate the sinus of Valsalva dissection eliminated or not. This
procedure does not demand advanced techniques and extra manipulations,
thereby reducing the operative complexity and shortening the operative
time. Conversely, this procedure may raise concerns regarding
pseudoaneurysm and late aortic regurgitation owing to aortic root
dilatation of the reconstructive sinus or abnormal aortic cusp motion.
During our following-up, there was no pseudoaneurysm and aortic
regurgitation, however, the effectiveness and safety of this procedure
should be confirmed through long‐term follow‐up studies.
Conclusion
In conclusion, “Sleeve” sinus Valsalva repair with Dacron patch for
aortic dissection limited to the non-coronary sinus or partial left and
right coronary sinus without involvement coronary artery ostia was
technically feasible and safe because of the satisfactory early results
regarding reconstructing the sinus of Valsalva and preserving aortic
valve function. A long‐term follow‐up is mandatory for the screening of
late complications.
Reference.
- Mussa FF, Horton JD, Moridzadeh R, et al. Acute aortic dissection and
intramural hematoma: a systematic review. JAMA 2016; 316 (7):754–63.
- Pape LA, Awais M, Woznicki EM, et al. Presentation, Diagnosis, and
Outcomes of Acute Aortic Dissection: 17-Year Trends from the
International Registry of Acute Aortic Dissection. Journal of the
American College of Cardiology. Jul 28; 2015 66(4):350–358.
- Movsowitz HD, Levine RA, Hilgenberg AD, et al Transesophageal
echocardiographic description of the mechanisms of aortic
regurgitation in acute type A aortic dissection: implications for
aortic valve repair. J Am Coll Cardiol 2000;36(3):884-890.
- Rylski B, Bavaria JE, Milewski RK, et al. Long-term results of
neomedia sinus valsalva repair in 489 patients with type A aortic
dissection. Ann Thorac Surg . 2014;98(2):582–589.
- Tang Y, Liao Z, Han L, Tang H, et al. Long-term results of modified
sandwich repair of aortic root in 151 patients with acute type A
aortic dissection. Interact CardioVasc Thorac Surg 2017; 25
(1):109–13.
- Fleischman F, Elsayed RS, Cohen RG, et al. Selective Aortic Arch and
Root Replacement in Repair of Acute Type A Aortic Dissection.Ann Thorac Surg . 2018;105(2):505–512.
- Malvindi PG, van Putte BP, Sonker U, et al. Reoperation after acute
type A Aortic dissection repair: a series of 104 patients. Ann Thorac
Surg. 2013; 95 (3):922–8.
- Ro SK, Kim JB, Hwang SK, et al. Aortic root conservative repair of
acute type A aortic dissection involving the aortic root: fate of the
aortic root and aortic valve function. J Thorac Cardiovasc Surg. 2013;
146 (5):1113–8.
- Zierer A, Voeller RK, Hill KE, et al. Aortic enlargement and late
reoperation after repair of acute type A aortic dissection. Ann Thorac
Surg. 2007; 84 (2):479–87.
- Estrera AL, Miller CC III, Villa MA, et al. Proximal reoperation after
repaired acute type A aortic dissection. Ann Thorac Surg. 2007; 83
(5):1603–9.
- David TE, Feindel CM, Bos J. Repair of the aortic valve in patients
with aortic insufficiency and aortic root aneurysm. J Thorac
Cardiovasc Surg. 1995;109(2):345‐351.
- Komiya T, Tamura N, Sakaguchi G, et al. Modified partial aortic root
remodeling in acute type A aortic dissection. Interact Cardiovasc
Thorac Surg. 2008;8(3):306‐309.
- Charitos EI, Stierle U, Sievers HH, et al. Valve‐sparing aortic root
remodeling with partial preservation of the intact native aortic
sinuses. Eur J Cardiothorac Surg. 2009;36(3):589‐591.
- Rylski B, Beyersdorf F, Blanke P, et al. Supracoronary ascending
aortic replacement in patients with acute aortic dissection type A:
what happens to the aortic root in the long run? J Thorac Cardiovasc
Surg 2013; 146 (2):285–90
- Geirsson A, Bavaria JE, Swarr D, et al. Fate of the residual distal
and proximal aorta after acute type a dissection repair using a
contemporary surgical reconstruction algorithm. Ann Thorac Surg 2007;
84 (6):1955–64.
- Yang B, Norton EL, Hobbs R, et al. Short- and long-term outcomes of
aortic root repair and replacement in patients undergoing acute type A
aortic dissection repair: Twenty-year experience. J Thorac
Cardiovasc Surg . 2019;157(6):2125–2136.
Fig 1: A tailored Dacron patch was inserted into the dissected layers
and a mattress stitch was used to fix the patch. Two 4mm Dacron strips
were placed inside and outside of the aorta and the new five-layers root
was sutured with 3/0 prolene continuous stitches.
Fig 2: The “Z”shape suture line was shown when reconstruct the sinus
of Valsalva. “Sleeve “technique was used to reconstructed the aortic
root. This technique reduced the tension of anastomosis when the aorta
contracting and relaxing, which may reduce the bleeding and residual
dissection in the sinus of Valsalva.
Fig 3: The computed tomography angiography showed normal aortic root
without endovascular leak or dissection around the sinus of Valsalva.