Reimplantation for Calcified Bicuspid Aortic Valve with Our Endoscopic Evaluation Technique

P0279 

Case Video Submission 

Yuta Kitagata (1), Taro Nakatsu (1), ETSURO SUENAGA (1)

(1) Kansai Electric power hospital, Osaka, Osaka

Yuta Kitagata    -  Contact Me
Kansai Electric power hospital

Taro Nakatsu    -  Contact Me
Kansai Electric power hospital

ETSURO SUENAGA    -  Contact Me
Kansai Electric power hospital

Yuta Kitagata    -  Contact Me
N/A

Objective: Repairing aortic regurgitation in cases involving calcified bicuspid valves remains a complex challenge. This presentation shows a successful repair of a calcified aortic valve through the reimplantation method using an ultrasound device, with the assistance of our developed endoscopic evaluation technique.
Case Video Summary: A 57-year-old male patient was diagnosed with moderate aortic valve regurgitation with fused and calcified right and left coronary cusps, a sinus of Valsalva measurement of 43 mm, and an enlarged ascending aorta measurement of 55 mm. After establishing cardiopulmonary bypass, distal anastomosis with a 28-mm Dacron woven graft right before the brachiocephalic artery and a patent foramen ovale closure via the right atrial were performed during circulatory arrest under hypothermia at a rectal temperature of 25°C. After trimming the aortic root and making coronary buttons, the raphe of the fused cusp was dissected and advanced calcifications were removed using an ultrasound device with attention not to perforate the cusps, which caused the mobility of the fused cusp to be improved. A 28-mm Dacron Valsalva-type graft was fixed to the ventriculo-aortic junction with twelve first-row sutures. After that, the commissure angle was fixed at 180 degrees to improve the mobility of the non-fused cusp, and the center of the fused cusp was resected in a triangular form to remove excess tissue. Our developed endoscopic evaluation method involved inserting a camera port with a balloon at the tip into the graft, inflating the balloon, and adding saline solution through a side tube to provide sufficient monitored pressure to the base. This allowed us to observe the aortic valve from the front using a camera. With a continuously monitored pressure of 70 mmHg applied to the valve, no regurgitation and great coaptation with matched free margins of the cusps were observed. Finally, the second-row suture was performed horizontally with polypropylene, and the shape of the aortic root was fixed. The total operation time was 5 hours and 40 minutes, aortic clamp time was 193 minutes, and circulation arrest time was 23 minutes, with no need for blood transfusion. The patient made a successful recovery and was discharged 10 days after the surgery, and follow-up echocardiography revealed no regurgitation.
Conclusions: In this case, we achieved optimal results by using our endoscopic evaluation method, which is particularly valuable for straightforward front-facing valve assessment under a continuously monitored pressure of 70 mmHg. Furthermore, when treating with bicuspid aortic valves, the cautious removal of calcifications using an ultrasound device can be advantageous in cases with a calcified valve, as calcified areas can impede mobility and complicate the reconstruction process. These techniques not only eliminate regurgitation in calcified valves but also improve valve patency and provide a sufficient effective orifice area.

Aortic Root