This document discusses aortic root enlargement using a posterior approach for redo aortic valve replacement. It provides details on the surgical technique used, which involves extending the aortotomy incision along the commissure between the left coronary and noncoronary sinuses across the anterior mitral leaflet and using a Dacron patch to enlarge the annulus. Results from a study of 25 patients found a hospital mortality rate of 8% due to low cardiac output, with 3 patients requiring reexploration for bleeding. The conclusion is that aortic root enlargement using this posterior approach can be done safely and does not increase surgical risk. However, the main limitation is the small number of patients and lack of long-term follow-

1. Posterior Approach Aortic rootPosterior Approach Aortic root
enlargement in Redo aortic Valve;enlargement in Redo aortic Valve;
Risk factorsRisk factors..
Mohamed HelmyMohamed Helmy M.D , Ass. Professor cardiothoracic surgeryM.D , Ass. Professor cardiothoracic surgery
Kasr el Einy univ.Kasr el Einy univ.
Osama Abouel Kasem M.DOsama Abouel Kasem M.D
Soleiman abdelhay M.D.Soleiman abdelhay M.D.
Department of cardiothoracic surgery Faculty of medicineDepartment of cardiothoracic surgery Faculty of medicine
Cairo University.Cairo University.

2. The main goal of aortic valve replacementThe main goal of aortic valve replacement
(AVR) for aortic stenosis is to releive the(AVR) for aortic stenosis is to releive the
pressure and volume overload on the leftpressure and volume overload on the left
ventricle, allowing regression of theventricle, allowing regression of the
ventricular mass.ventricular mass.

3. it is not always possible to avoid patient–it is not always possible to avoid patient–
prosthesis mismatch (PPM) usingprosthesis mismatch (PPM) using
standard implantation procedures,standard implantation procedures,
particularly in small patients and in thoseparticularly in small patients and in those
with a large body surface area (BSA).with a large body surface area (BSA).

4. Is a small annulus an
inconvenience?
Indicators:
Earlymortality
Hemodynamic impairment
Functional status: NYHA
Re-operations
Late mortality

5. Small valves effect
Hemodynamic parameters
Gradient regression
Incomplete in 19
Gradients increase with time in mismatch
Mass regression Not significant in 19mm.
Better in ≥21mm.
Sim EK, Orszulak TA, Scaff HV and Shub C. Influence of prosthesis
size on change in left ventricular mass following aortic valve
replacement. European J Cardio Thorac Surg1994;8:293-7. (Mayo
group).

6. Hemodynamic parameters
Cardiac index when EOA< 0,85cm2/m2
Decreases after 3 years .
Hemodynamic continues to deteriorate with time.
P, Pibarot Dumesnil JG, Lemieux M, Cartier P, Metras J, Durand
LG. Impact of prosthesis-patient mismatch on hemodynamic and
symptomatic status, morbidity and mortality after aortic valve
replacement with a bioprosthetic valve. J of Heart valve disease
1998;2:207-16.

7. Mismatch and negative
effect on Symptomatic improvement
Less NYHA improvement in mismatch p< 0,009
independently to other predictors.
P, Pibarot Dumesnil JG, Lemieux M, Cartier P, Metras J, Durand
LG. Impact of prosthesis-patient mismatch on hemodynamic and
symptomatic status, morbidity and mortality after aortic valve
replacement with a bioprosthetic valve. J of Heart valve disease
1998;2:207-16

8. Although ARE procedures are 30 years old, It isAlthough ARE procedures are 30 years old, It is
practiced by only a few surgical groups.practiced by only a few surgical groups.
The largest series (The largest series (nn = 669) belongs to the= 669) belongs to the
Toronto groupToronto group In their first report (1997In their first report (1997), they), they
have shown that ARE increased the cross-clamphave shown that ARE increased the cross-clamp
time, the rate of re-operation for bleeding andtime, the rate of re-operation for bleeding and
the operative mortality rate (7.2% vs 3.5%),the operative mortality rate (7.2% vs 3.5%),
compared with patients who underwent AVRcompared with patients who underwent AVR
alone.alone.
ThoracThorac CardiovascCardiovasc Surg.Surg. 1979 Sep;78(3):402-12.1979 Sep;78(3):402-12.
Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitralPatch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral
leaflet. New operative technique.leaflet. New operative technique.
ManouguianManouguian SS,, Seybold-Seybold-EptingEpting WW..

9. After this initial negative experience, thisAfter this initial negative experience, this
group presentedgroup presented new results in 2007new results in 2007,,
revealing a steeper decline in the mortalityrevealing a steeper decline in the mortality
rate (down to 2.9%), probably a result ofrate (down to 2.9%), probably a result of
the growing experience.the growing experience.

10. Freedom from valve-related
mortality
75±5% ‘mismatch’
84±2% ‘normal’.
(227 ‘mismatch’ / 2981pts)
Rao V, Jamieson WR, Ivanov J, Armstrong S, David TE. Prosthesis-
patient mismatchaffects survival after aortic valve replacement.
Circulation 2000; 102(19 Supp 3): III5-9,)(Toronto)

11. Why ENLARGE the annulus?
Small valves not ideal in large men BSA >
1,9m2
Hemodynamics are not optimal with small
valves and further deteriorate over time
Occasionally have to re-operate patients
who as adults received

12. Who to ENLARGE?
≤19 mm aortic annulus
BSA 1,9m2
IEOA 0,85cm2/m2.

13. Operative mortality?
Equal to normal procedure when done
‘routinely’
114/657pts; Mean age 72±11
(Luis J Castro, JM Arcidi, AL Fisher, VA
Gaudiani. Routine enlargement of thesmall
aortic root: a preventive strategy to minimize
mismatch. Ann ThoracSurg 2002;74:31-36.)

14. Long-term results
Survival at 10 yrs 85,7% ‘enlarged’ versus
62,7% ‘small valves’
Freedom valve related events81% versus
58,8%.
(Kitamura M, Satoh M, Hachida M, Endo M,
Hashimoto A, Koyanagi H. Aortic
valvereplacement in small aortic annulus with or
without annular enlargement. Journal of Heart
Valve disease 1996: Suppl 3: S 289-93).

15. Sudden late death
increases in 19mm with BSA≥1,9
Kratz JM, Sade RM, Crawford FA, Crumbley AJ, Stroud
MR. The risk of small St. Jude aortic valve prostheses.
Ann Thorac Surg 1994;57:1114-1118

16. MethodsMethods::
We reviewed perioperative outcomesWe reviewed perioperative outcomes
among patients undergoing redo aorticamong patients undergoing redo aortic
valve replacement with aortic rootvalve replacement with aortic root
enlargement at our institution betweenenlargement at our institution between
January 2008 and December 2012. RiskJanuary 2008 and December 2012. Risk
factors for operative death were evaluatedfactors for operative death were evaluated
by means of multivariable analysis.by means of multivariable analysis.

17. Total of 25 patients 13 males and 12Total of 25 patients 13 males and 12
females had repeated aortic valvefemales had repeated aortic valve
replacement , mean agereplacement , mean age 3636.64 ± 4.10..64 ± 4.10.
TheThe indicationsindications for reoperation were:for reoperation were:
prosthetic valve malfunction due toprosthetic valve malfunction due to
patient valve mismatch , pannus, infectivepatient valve mismatch , pannus, infective
endocarditis and bioprosthetic valveendocarditis and bioprosthetic valve
degeneration.degeneration.

18. The size of explanted prostheses rangedThe size of explanted prostheses ranged
between 19–21 mm while the size of thebetween 19–21 mm while the size of the
implanted prostheses ranged betweenimplanted prostheses ranged between
21–25 mm .21–25 mm .
Root enlargement was accomplished byRoot enlargement was accomplished by
Manougian technique.Manougian technique.

19. Table 1: Demographic data
Variables
Number of
patients (%)
n=25
Deaths (%)
n=2
P value
Mean age(y)
±SD
36.64 ± 4.10
Male (%) 13(52.00) 1(7.70) 0.549
NYHA class
(%)
1 0(0.00) 0(0.00)
2 3(12.00) 0(0.00)
3 14(56.00) 1(7.14)
4 8(32.00) 1(12.50) 0.026*
Diabetic
patients (%)
8(32.00) 1(12.50) 0.072
Chi- square test p<0.05

20. Table 2: Preoperative echocardiography.
Echocardio
graphy
Number of
patients (%)
n=25
Deaths
(%)
n=2
P value
LVED≤
5.30 cm
13(52.00) 0(0.00)
LVED>
5.30 cm
12(48.00) 2(16.67) 0.841
LVES ≤ 3.9
cm
15(60.00) 0(0.00)
LVES> 3.9
cm
10(40.00) 2(20.00) 0.317
EF%≤ 50% 17(68.00) 2(11.76)
EF% >50% 8(32.00) 0(0.00) 0.072

21. Table : Operative details
Variables
Number of patients
(%)
n=25
Deaths (%)
n=2
P value
Cross clamp
≤ 90 min 17(68.00) 0(0.00)
>90 min 8(32.00) 2(25.00) 0.072
Bypass time
≤ 120 min 21(84.00) 0(0.00)
>120 min 4(16.00) 2(50.00) 0.001*

22. Echocardiograp
hy
Number of patients (%)
n=25
Deaths (%)
n=2
P value
LVED≤ 5.30
cm
13(52.00) 0(0.00)
LVED> 5.30
cm
12(48.00) 2(16.67) 0.841
LVES ≤ 3.9 cm 15(60.00) 0(0.00)
LVES> 3.9 cm 10(40.00) 2(20.00) 0.317
EF%≤ 50% 17(68.00) 2(11.76)
EF% >50% 8(32.00) 0(0.00) 0.072

24. How to ENLARGE the annulus?
Manougian
Manougian technique

25. Surgical TechniqueSurgical Technique
A transverse aortotomy was made and after explanting the oldA transverse aortotomy was made and after explanting the old
valve , excessive fibrotic tissue was debrided ,If the annulus didvalve , excessive fibrotic tissue was debrided ,If the annulus did
accommodate a 19-mm obturator or less, root enlargement wasaccommodate a 19-mm obturator or less, root enlargement was
undertaken.undertaken.
The aortotomy incision was extended along the commissureThe aortotomy incision was extended along the commissure
between the left coronary and the noncoronary sinuses, across thebetween the left coronary and the noncoronary sinuses, across the
centre of the fibrous origin of the anterior mitral leaflet 1.5 to 2 cm .centre of the fibrous origin of the anterior mitral leaflet 1.5 to 2 cm .
A Dacron patch was then used in all the patients to enlarge theA Dacron patch was then used in all the patients to enlarge the
aortic annulus with continuous 4/0 Proline sutures .The aortic rootsaortic annulus with continuous 4/0 Proline sutures .The aortic roots
were enlarged by 2 to 4 mm . The appropriate valve sizerswere enlarged by 2 to 4 mm . The appropriate valve sizers

33. ResultsResults
The total number of hospital mortality wasThe total number of hospital mortality was
2 cases (8%),due to low cardiac output.2 cases (8%),due to low cardiac output.
Rexploration was undertaken in the 3Rexploration was undertaken in the 3
cases due to bleeding with proper controlcases due to bleeding with proper control
of bleedingof bleeding

34. ConclusionConclusion
Aortic root enlargement using posterior
approach does not increase the surgical
risk and can be done safely.

35. Limitation of the studyLimitation of the study
The most important limitation of theThe most important limitation of the
study was the small number of patientsstudy was the small number of patients
and failure to provide long-term follow-up.and failure to provide long-term follow-up.
We encourage prospective operativeWe encourage prospective operative
strategies to minimize predictablestrategies to minimize predictable
mismatch,mismatch,