Aortic Root Enlargement Procedures
14-5-1. Posterior Root Enlargement
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.
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.
- Figure 14-49. Glutaraldehyde-treated pericardium is stitched over the lower aortotomy extension.
pericardial patch pericardial patch caud ceph
- Figure 14-50. The pericardial patch is retracted anteriorly and seen from outside the aorta.
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
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.
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.
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.
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.
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
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
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.
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
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.
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
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
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
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
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
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
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
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.
- R*
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
ceph caud
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.
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
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
- 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.
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