Aortic Root Enlargement Procedures

14-5-1. Posterior Root Enlargement

Bicuspid Aortic Valve

aortic valve cusps

Figure 14-47. With cardiopulmonary bypass, aortic clamping, and cardioplegia with profound local cardiac cooling, a proximal ascending aortotomy is made. A bicuspid stenotic and dysplastic valve is seen. After it is determined that valvuloplasty is not possible, the valve leaflets are excised.

aortic valve cusps

Figure 14-47. With cardiopulmonary bypass, aortic clamping, and cardioplegia with profound local cardiac cooling, a proximal ascending aortotomy is made. A bicuspid stenotic and dysplastic valve is seen. After it is determined that valvuloplasty is not possible, the valve leaflets are excised.

Pulmonary Valvuloplasty

anterior mitral leaflet extended aortotomy annulus

Figure 14-48. The aortotomy is extended caudad and posteriorly through the valve annulus to the base of the anterior mitral leaflet. With this technique, the annulus can be enlarged by up to 4 to 5 mm.

anterior mitral leaflet extended aortotomy annulus

Figure 14-48. The aortotomy is extended caudad and posteriorly through the valve annulus to the base of the anterior mitral leaflet. With this technique, the annulus can be enlarged by up to 4 to 5 mm.

Images Extended Aortic Valvuloplasty
Figure 14-49. Glutaraldehyde-treated pericardium is stitched over the lower aortotomy extension.
Pericardial Patches
pericardial patch

caud ceph

Figure 14-50. The pericardial patch is retracted anteriorly and seen from outside the aorta.

Figure 14-50. The pericardial patch is retracted anteriorly and seen from outside the aorta.

Aortic Root Enlargement

prosthetic valve valve stitches in patch pericardial patch

Figure 14-51. A prosthetic valve is implanted at the level of the native aortic valve annulus, and the pericardial patch now comprises part of that annulus. To complete the repair, the remaining pericardial patch is stitched over the aortotomy.

prosthetic valve valve stitches in patch caud pericardial patch

Figure 14-51. A prosthetic valve is implanted at the level of the native aortic valve annulus, and the pericardial patch now comprises part of that annulus. To complete the repair, the remaining pericardial patch is stitched over the aortotomy.

14-5-2. Konno Procedure with a Prosthetic Valve caud

Konno Procedure

aortic valve cusps

Figure 14-52. The aortotomy is made in a longitudinal direction and to the left of the right coronary artery orifice. The severely scarred valve cusps are beyond repair, and it is decided to proceed with valve replacement and anterior root enlargement.

aortic valve cusps caud

Figure 14-52. The aortotomy is made in a longitudinal direction and to the left of the right coronary artery orifice. The severely scarred valve cusps are beyond repair, and it is decided to proceed with valve replacement and anterior root enlargement.

His Bundle Aortic Valve

aortotomy right ventriculotomy ventricular septum

Figure 14-53. An adjacent incision is made in the anterior wall of the right ventricular outflow tract to expose the septum.

aortotomy right ventriculotomy ventricular septum

Figure 14-53. An adjacent incision is made in the anterior wall of the right ventricular outflow tract to expose the septum.

Aorta Root Enlargement

valve leaflet ventricular septal Incision

Figure 14-54. The aortic valve annulus is incised by working to the left of the right coronary orifice. The incision extends into the upper part of the ventricular septum cephalad to the His' bundle. Valve leaflets are excised in preparation for valve replacement.

caud valve leaflet ventricular septal Incision

Figure 14-54. The aortic valve annulus is incised by working to the left of the right coronary orifice. The incision extends into the upper part of the ventricular septum cephalad to the His' bundle. Valve leaflets are excised in preparation for valve replacement.

Parche Pericardio Dacr

patch in ventricular septal defect

Figure 14-55. A woven Dacron® patch is tailored to conform to the iatrogenic VSD and adjacent aortotomy. The lower part of the patch is placed over the VSD with interrupted felted mattress sutures, placing the patch on the left ventricular surface of the septum.

patch in ventricular septal defect

Figure 14-55. A woven Dacron® patch is tailored to conform to the iatrogenic VSD and adjacent aortotomy. The lower part of the patch is placed over the VSD with interrupted felted mattress sutures, placing the patch on the left ventricular surface of the septum.

Suture Pass

native valve annulus ventricular septal defect patch

Figure 14-56. The patch is retracted anteriorly and interrupted valve sutures are placed in the native valve annulus. Additional anterior valve sutures pass through the patch.

native valve annulus

Figure 14-56. The patch is retracted anteriorly and interrupted valve sutures are placed in the native valve annulus. Additional anterior valve sutures pass through the patch.

ventricular septal defect patch ceph caud ceph caud

Prosthetic Valve

__ prosthetic valve

Figure 14-57. After the valve orifice is sized, an appropriate prosthetic valve is stitched in place in the subcoronary position. At least 60% of the valve annulus should be placed in the native annulus. Significant enlargement of the left ventricular outflow tract is accomplished, allowing for placement of a larger prosthesis.

__ prosthetic valve

Figure 14-57. After the valve orifice is sized, an appropriate prosthetic valve is stitched in place in the subcoronary position. At least 60% of the valve annulus should be placed in the native annulus. Significant enlargement of the left ventricular outflow tract is accomplished, allowing for placement of a larger prosthesis.

caud

Pulmonary Annulus

annulus of valve patch over ventricular septal defect

Figure 14-58. The upper segment of the Dacron® patch is stitched to the aortotomy with a continuous suture. Felt pledgets of valve sutures are seen and the repaired VSD is caudad to the valve annulus.

annulus of valve patch over ventricular septal defect caud

Figure 14-58. The upper segment of the Dacron® patch is stitched to the aortotomy with a continuous suture. Felt pledgets of valve sutures are seen and the repaired VSD is caudad to the valve annulus.

Aortic And Pulmonic Areas

pericardial patch over right ventricular outflow area patch covering aortic wall patch

Figure 14-59. A pericardial patch is stitched over the right ventriculotomy and extends in continuity across the surface of the Dacron® patch. Blood that leaks from the Dacron® patch is collected beneath the pericardial patch and drains to the right ventricle.

pericardial patch over right ventricular outflow area patch covering aortic wall patch

Figure 14-59. A pericardial patch is stitched over the right ventriculotomy and extends in continuity across the surface of the Dacron® patch. Blood that leaks from the Dacron® patch is collected beneath the pericardial patch and drains to the right ventricle.

14-5-3. Konno Procedure with a Homograft Valve

Right Ascending Coronary Artery

ascending aorta right coronary artery ascending aorta right coronary artery ceph

caud

Figure 14-60. The right coronary artery is in the usual anterior aortic root location.

Figure 14-60. The right coronary artery is in the usual anterior aortic root location.

Human Aortic Root

aortotomy to left of right coronary artery right ventriculotomy aortic valve cusps ventricular septal incision

Figure 14-61. A longitudinal incision in the proximal aorta is directed to the left of the right coronary artery orifice. An adjacent right ventriculotomy is made, and the aortic valve annulus is incised, extending this incision into the ventricular septum.

aortotomy to left of right coronary artery right ventriculotomy aortic valve cusps

Figure 14-61. A longitudinal incision in the proximal aorta is directed to the left of the right coronary artery orifice. An adjacent right ventriculotomy is made, and the aortic valve annulus is incised, extending this incision into the ventricular septum.

ventricular septal incision caud

Rat Pulmonary Artery

mit rat leaflet of ho mo graft patch homograft to native annulus stitch ventricular septal incision

Figure 14-62. Native aortic valve cusps are excised. An aortic valve homograft is tailored, leaving a large patch of homograft wall anteriorly. The homograft is positioned so that its mitral leaflet is located anteriorly. The homograft is stitched to the native valve annulus with a continuous monofilament suture, placing this stitch immediately below the homo-graft valve annulus.

mit rat leaflet of ho mo graft patch homograft to native annulus stitch

Figure 14-62. Native aortic valve cusps are excised. An aortic valve homograft is tailored, leaving a large patch of homograft wall anteriorly. The homograft is positioned so that its mitral leaflet is located anteriorly. The homograft is stitched to the native valve annulus with a continuous monofilament suture, placing this stitch immediately below the homo-graft valve annulus.

caud ventricular septal incision

Aortic Pulmonary Septum

mitral leaflet of homograft ventricular septum

Figure 14-63. The homograft mitral leaflet is used to close the VSD with interrupted felted mattress sutures. These stitches are passed from the left ventricular surface of the septum and then through the adjacent homograft mitral leaflet. Pledgets are used on both surfaces of the septum.

mitral leaflet of homograft

Figure 14-63. The homograft mitral leaflet is used to close the VSD with interrupted felted mattress sutures. These stitches are passed from the left ventricular surface of the septum and then through the adjacent homograft mitral leaflet. Pledgets are used on both surfaces of the septum.

ventricular septum

Homograft Aortic

aortotomy posterior homograft to native aorta suture anterior wall of homograft

Figure 14-64. Homograft aortic wall is removed from two posterior sinuses of Valsalva of the graft. The central homograft commissure is in the midline, and the upper rim of the homograft is stitched to the posterior wall of the native ascending aorta.

aortotomy posterior homograft to native aorta suture

Figure 14-64. Homograft aortic wall is removed from two posterior sinuses of Valsalva of the graft. The central homograft commissure is in the midline, and the upper rim of the homograft is stitched to the posterior wall of the native ascending aorta.

anterior wall of homograft

Aorta Stitches

anterior homograft wall to native aorta suture

Figure 14-65. The anterior homograft aortic wall is stitched to the aortotomy of the native aorta.

anterior homograft wall to native aorta suture homograft mitral leaflet stitched to ventricular septum right ventriculotomy

Figure 14-65. The anterior homograft aortic wall is stitched to the aortotomy of the native aorta.

anterior wall of homograft stitched to native aorta

caud

Right Ventricle Homograft

harvested homograft patch in right ventricular outflow

Figure 14-66. A homograft aortic wall patch that was harvested in the tailoring process is used to reconstruct the right ventricular outflow tract. The homograft aortic wall patch covers the ventriculotomy and is stitched to the anterior homograft valve annulus.

Figure 14-66. A homograft aortic wall patch that was harvested in the tailoring process is used to reconstruct the right ventricular outflow tract. The homograft aortic wall patch covers the ventriculotomy and is stitched to the anterior homograft valve annulus.

caud harvested homograft patch in right ventricular outflow

14-5-4. Ross-Konno Procedure caud

Ross Pulmonary Autograft Procedure

aortotomy autograft

Figure 14-67. After establishing cardiopulmonary bypass with moderate hypothermia, aortic clamping, cardioplegic arrest, and profound local cooling, the pulmonary autograft is harvested. The main pulmonary artery has been divided proximal to the branches and the proximal vessel with the valve was harvested from the right ventricule. A circumferential 0.5-cm muscle bar was taken with the graft. Here, the ascending aorta has been opened in a longitudinal direction, extending this excision across the aortic valve annulus into the ventricular septum. This relieves the left ventricular outflow tract obstruction.

aortotomy autograft explani site in right ventricular outflow ventricular septal incision

Figure 14-67. After establishing cardiopulmonary bypass with moderate hypothermia, aortic clamping, cardioplegic arrest, and profound local cooling, the pulmonary autograft is harvested. The main pulmonary artery has been divided proximal to the branches and the proximal vessel with the valve was harvested from the right ventricule. A circumferential 0.5-cm muscle bar was taken with the graft. Here, the ascending aorta has been opened in a longitudinal direction, extending this excision across the aortic valve annulus into the ventricular septum. This relieves the left ventricular outflow tract obstruction.

caud autograft muscle ridge ceph caud

Aortic Enlargement

muscle ridge autograft leaflets

Figure 14-68. Prior to implantation, the autograft leaflets are inspected and found to be normal.

autograft leaflets

Figure 14-68. Prior to implantation, the autograft leaflets are inspected and found to be normal.

Aortic Ridge Picture

annulus marking stitches expiant site ventricular septal defect

Figure 14-69. Aortic valve leaflets are excised, leaving a 1-mm segment of leaflet attached to the native annulus. The new left ventricular outflow tract opening is marked with three trifurcating stitches. These are placed opposite the native sinuses of Valsalva and will be inserted near the middle of each autograft sinus of Valsalva.

annulus marking stitches expiant site ventricular septal defect

Figure 14-69. Aortic valve leaflets are excised, leaving a 1-mm segment of leaflet attached to the native annulus. The new left ventricular outflow tract opening is marked with three trifurcating stitches. These are placed opposite the native sinuses of Valsalva and will be inserted near the middle of each autograft sinus of Valsalva.

autograft autograft ceph caud

Endometriosis Ovarian Location

stitches for ventricular septal defect closure

Figure 14-70. The trifurcating stitches are placed in the proximal autograft muscle bar, opposite the mid part of each autograft leaflet. Multiple interrupted felted stitches are passed through the ventricular septum from left ventricle into right ventricle in preparation for closing the VSD.

stitches for ventricular septal defect closure

Figure 14-70. The trifurcating stitches are placed in the proximal autograft muscle bar, opposite the mid part of each autograft leaflet. Multiple interrupted felted stitches are passed through the ventricular septum from left ventricle into right ventricle in preparation for closing the VSD.

Valsalva Dacron Graft

autograft anterior muscle bar

VSD patch

Figure 14-71. A Dacron® patch is placed over the VSD utilizing previously inserted stitches. The autograft will be attached to the native aortic valve annulus with multiple interrupted fine polypropylene sutures. In situ the graft fits well. The VSD patch will be attached to the anterior muscle bar with additional interrupted sutures.

autograft anterior muscle bar

VSD patch caud

Figure 14-71. A Dacron® patch is placed over the VSD utilizing previously inserted stitches. The autograft will be attached to the native aortic valve annulus with multiple interrupted fine polypropylene sutures. In situ the graft fits well. The VSD patch will be attached to the anterior muscle bar with additional interrupted sutures.

caud

What The Native Annulus

native aorta autograft

VSD patch right ventriculotomy

Figure 14-72. Working inside the native aorta, the posterior wall of the graft sinuses of Valsalva is tailored and then the graft is stitched to the posterior native aorta below and around the coronary orifices. The posterior graft commissure is also attached to the posterior native aorta. The anterior wall of the autograft is stitched to the opening in the native aorta.

native aorta autograft

VSD patch pulmonary ho mo g raft anterior muscle bar ventriculotomy

Figure 14-72. Working inside the native aorta, the posterior wall of the graft sinuses of Valsalva is tailored and then the graft is stitched to the posterior native aorta below and around the coronary orifices. The posterior graft commissure is also attached to the posterior native aorta. The anterior wall of the autograft is stitched to the opening in the native aorta.

caud right ventriculotomy

Pulmonary Valve Homograft
Figure 14-73. A pulmonary valve homograft with attached main pulmonary artery is used for reconstruction of the right ventricular outflow tract. Its muscle bar is stitched to the posterior right ventricle and the anterior graft muscle bar is stitched to the ventriculotomy.
Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

Get My Free Ebook


Post a comment