Approach for small aortic root - RM Solutions

Hani K. Najm MD
King Abdulaziz Cardiac Centre
Riyadh.

Patient-Prosthesis Mismatch:
Residual gradient
Progressive LV dysfunction
Hemolysis.
Bulky bioprostheses /small annulus

Effective orifice area index=
Effective orifice area/BSA(Sq.m)
2.0 0r above is normal
0.67 Severe stenosis
Rahimtoola first described 1978
Pibarot and Dumensnil (1998) defined PPM to be effective
orifice area indexed to BSA of 0.85m 2 /m 2 or less

Root replacement
Homografts
Stentless xenografts
Ross operation alone.
Posterior annular enlargement:
Nicks’ technique.
Manouguian technique.
Anterior annular enlargement:
Rastan-Konno operation.
Konno-Ross operation.
Apico-aortic conduit.

It is usually taken by the surgeon operating and
on a feeling that the annular size is smaller than
required for that patient depending on :
Pt age
Comorbid conditions
Anatomy of the aortic root
Surgeon’s judgment
Surgeon’s comfort level

Nicks technique
Manouguian technique

Aortotomy extended towards
aortic annulus related to the
middle of non-coronary cusp
(NCC).
Incision extended across aortic
annulus and then across mitral
annulus and into the body of
anterior mitral leaflet (AML).
Aortic annulus opens up in the
form of inverted-V with apex
towards AML.

A v-shaped dacron patch
sutured to the edges of
this incision thus enlarges
aortic annulus by 2-3 cm.
Interrupted sutures for
holding prosthesis passed
circumferentially into
aortic annulus except
posteriorly where they are
passed through dacron
patch.

Oblique aortotomy extended towards and across
the commissure between LCC and NCC, thus
dividing the annulus.
Incision extended vertically across the triangular
area between two cusps and thereafter into the
aortic-mitral fibrous continuity.

Tear-drop shaped Dacron patch is sutured to the
defect to enlarge the posterior annulus.
Valve sutures are brought from outside the patch
at annular level.
Rest of the patch is used to close aortotomy
incision.

Challenging problem

Required more commonly in children.
Indicated when aortic annulus and left
ventricular outflow tract are narrow (Congenital
tunnel stenosis).
Longitudinal anterior aortotomy is extended across
anterior annulus and inter-ventricular septum to
open LVOT.
Incision extended to open RV outflow tract.

Dacron/ bovine pricardial patch is used to enlarge
LVOT and prosthesis is inserted.
Second dacron/bovine pericardial patch is used
to close right ventricular outflow incision.

For patients suitable for autograft aortic valve
replacement who have tunnel-type LVOT.
Rastan-Konno approach is used to expose and
open LVOT.
Pulmonary autogaft is harvested and used as in
classical Ross procedure.

‣ LVOT tunnel like
‣ Aortic regurgitation after balloon angioplasty in
neonatal age with small annulus
‣ Mismatch in the aortic and pulmonary size.
‣ Pulmonary autograft ideal for:
performance, growth potential, avoidance of
anticoagulation.

Combine the Rastan-Konno
and a pulmonary Autograft
like in the Ross procedure.

Ross/Konno procedure

Apico-aortic valved conduit

It is an alternative when there is:
• Severe left ventricular
hypertrophy.
• Diminutive left ventricular
size.
• Diffuse thickness of the IVS.
• Multiple aortic valve
replacements with small
aortic root.

Apico-aortic conduit

1989 – 2006
712 with small aortic roots
540 AVR with

Aortic cross clamp was 9.9 min longer in
AVR+ARE
No difference in reopening, stroke or mortality
Post op
Lower gradient
Larger IOA
Lower PPM
No difference in survival

2004-2006
11 women aged >70y
AVR using 17 mm Regent st. Jude prosthesis
Avg BSA 1.33

Small aortic roots still poses a difficult problem
to the surgeon
There is no clear objective data to suggest the
exact indication for ARE
The decision to enlarge the root is dependent on
the surgeon evaluation and experience
Presence of PPM may increase gradients and
reduce IEO but does not affect survival

In Infants
Small root with no SAS,
Small root with SAS
In Children
Small root with no SAS,
Small root with SAS
In Adults
Small root, large BSA
Small root, small BSA (