Implantation techniques of freehand subcoronary aortic valve and root replacement with a cryopreserved allograft for aortic root abscess

  • Charles A. Yankah
  • M. Pasic
  • Y. Weng
  • Roland Hetzer


Prior to 1972, the surgical results of aortic root abscesses treated with prosthetic valves varied and, being associated with a high rate of early recurrent infection and mortality, were not very satisfactory. Consequently, in 1972 Donald Ross introduced the use of the aortic allograft, which is a completely biological tissue for replacing the infected aortic valve (see Figs. 27) [1, 2, 3, 4]. This operation technique was initially used for reconstruction of a tunnel-type left ventricular outflow tract due to congenital obstruction and was then adopted for treating aortic root abscesses. The original procedure was described by Hugh Bentall and Antony de Bono in 1968 [5].
Fig. 2.

a Schematic presentation of the anticipated proximal (lower) line below the infraannular abscess cavity in the region of the aortic mitral fibrous septum. The lower line sutures: Twocolor multiple interrupted polypropylene (Prolene) 4-0 sutures buttressed by equine pericardial pledgets are placed at the base of the infraannular abscess cavity at the native mitral annulus and in the muscle of the left ventricular outflow tract in healthy tissue. The sutures are placed further toward the remaining circumference at the left and right coronary aortic annulus to complete the anticipated lower proximal line. b Reconstructed aortic mitral fibrous septum with a pericardial patch

Fig. 3.

a A short segment aortic allograft with anterior mitral leaflet. b The lower edge of the allograft aortic anterior mitral anterior leaflet (AML) is fed with two-colour multiple interrupted polypropylene (Prolene) 4-0 mattress sutures in such a fashion that they fit to the anticipated lower suture line below the infraannular abscess cavity. This technique ensures anatomic insertion of the allograft. c The allograft is lowered down with the AML in front of the abscess cavity in order to exclude the abscess cavity from the blood circulation. The sutures are tied down toward the noncoronary and right coronary annulus and fixed, thus excluding the abscess cavity from the LVOT. The sutures are placed further toward the remaining circumference at the left and right coronary aortic annulus to complete the circumference of the anticipated lower proximal line. The subvalvular muscular skirt of the allograft is then fed with the lower line sutures so that they fit to the anticipated proximal anastomosis with the native aortic annulus. The allograft cylinder is then inverted into the left ventricle to allow reliable tying down of the remaining sutures and to complete the fixation of the allograft. The technique allows the abscess cavity to drain into the pericardium

Fig. 4.

aThe allograft is carefully pulled out from the left ventricular outflow tract for reimplantation of the coronary arteries. The reimplantation of the coronary arteries is technically accomplished in two ways: 1. Anastomosis with a circumcised coronary arteries as buttons, 2. Direct anastomosis using a continuous interrupted 4-0 Prolene sutures. b Schematic reimplantation of the left coronary artery. The allograft is gently pushed caudally to allow a better view. Direct end-to-side anastomosis of the native left coronary artery with the adjacent aortic sinus at the site of the allograft left coronary ostium. c Schematic reimplantation of the right coronary artery. The allograft is gently pushed cranially to allow a better view. Direct end-to-side anastomosis of the native right coronary artery with the adjacent sinus at the site of the allograft right coronary ostium. Testing for the tightness of the proximal suture line. After testing of the tightness of the proximal line during the repeat induction of the blood cardioplegia the distal end-to-end anastomosis begins

Fig. 5.

a The distal end of the allograft (the sinotubular junction) is anastomosed with the native ascending aorta end-to-end by continuous suture technique using 4-0 polypropylene beginning at the posterior wall, reinforcing the suture line with the surrounding tissue of the native aortic wall. The sinotubular junction which is usually 90% the size of the aortic annulus is geometrically matched to the native ascending aorta. b Completed procedure of a total aortic root replacement as a freestanding root with reimplantation of the coronary arteries

Fig. 6.

Scalloped left and right sinuses of the aortic allograft as described by Ross with intact nonconcoronary sinus wall for freehand subcoronary aortic valve replacement. The technique reduces the probability of distortion of the allograft. The right and the left commissures are securely positioned with the intact noncoronary sinus wall of the allograft to provide adequate leaflet coaptation. a View of the anticipated second row suture line which begins below the midpoint of the coronary ostium with secured coaptation of the aortic valve leaflets. b Schematic presentation of completion of the two-row lower proximal suture line (the first row suture line is not visible) and the freestanding noncoronary sinus wall of the allograft. c Completed second row suture line below the left coronary artery ostium with adequate coaptation of the aortic valve leaflets

Fig. 7.

Schematic presentation of the technique for closing the aortotomy. The freestanding noncoronary sinus wall of the allograft can be used for enlarging the aortic root, if necessary; otherwise it will be incorporated into the aortotomy closure and fixed to the native noncoronary sinus wall. a Left: Schematic presentation of the noncoronary sinus wall prior to closure of the aortotomy. b Right: Schematic presentation of the noncoronary sinus wall of the scalloped allograft. This is used to enlarge the native aortic noncoronary as described by Ross and to accommodate the noncoronary segment of the allograft comfortably in the aortic root without it being squeezed and causing central valve incompetence. The enlargement of the noncoronary sinus of a small aortic root was originally described by Nicks using pericardium after prosthetic aortic valve replacement


Aortic Valve Aortic Root Aortic Valve Replacement Left Ventricular Outflow Tract Aortic Annulus 
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Copyright information

© Springer-Verlag Berlin Heidelberg 2010

Authors and Affiliations

  • Charles A. Yankah
    • 1
  • M. Pasic
  • Y. Weng
  • Roland Hetzer
    • 1
  1. 1.Deutsches Herzzentrum Berlin & Charité Medical University BerlinBerlinGermany

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