HAARTbeatMD Article

Selective Sinus Replacement for Asymmetric Aortic Root Aneurysms

A key advantage of using a HAART Annuloplasty Device for aortic root surgery is the ability to technically separate aortic annuloplasty plus valve repair from the root aneurysm repair. The Yacoub (i.e. remodeling) procedure is a simple, less complicated approach to root aneurysm reconstruction but has no inherent means for annuloplasty. Combining the Yacoub procedure with ring annuloplasty using the HAART Device avoids the pitfall of late annular dilation associated with isolated Yacoub procedures, and provides a simpler, more adaptable root aneurysm repair. (1) In the case of asymmetric aortic root aneurysms, this combination facilitates the elegant solution of selective sinus replacement of only the enlarged sinuses. In the following case presentation, the advantage of the remodeling procedure in combination with geometric ring annuloplasty is presented.

After the aortic valve repair, attention is turned to aortic root remodeling. With selective sinus replacement in asymmetric root aneurysms, an objective method for determining which sinus(es) is enlarges, and therefore, which should be replaced is available. Normally, segmental sinus circumference should be just a little larger than the leaflet free-edge length, and using the same ball sizer as fit the leaflets, segmental sinus circumference is measured after the valve repair. In the following video, Dr. Downey demonstrates a selective sinus replacement approach to address asymmetric root aneurysm.

In this case, the right sinus segmental circumference was almost twice the corresponding leaflet free-edge length, and the non-coronary sinus also was much larger. However, the left sinus was of normal size (again relative to leaflet free-edge length); thus, the left sinus was not replaced. The non-coronary and right sinuses were excised, and the right coronary button was developed. A 30 mm Valsalva graft (7 mm larger than the annuloplasty ring) was chosen, and the bottom skirt was removed. Three 120º tongues were developed by cutting the 120º lines on the graft doughnut vertically (about 2/3rds up the Valsalva doughnut), and corners of the tongues were removed. The right and non-coronary tongues were sutured to their respective sinuses, starting the suture lines at the nadir of the tongue and sinus with horizontal mattress sutures that everted the graft edge. The running suture line then was carried up the sinus toward the top of the commissure, incorporating the ring pledgets into the closure to lock the graft into the ring.

A strip of autologous pericardium or Teflon felt can be incorporated into the sinus suture line as an added precaution for hemostasis. The vertical 120º incision in the graft doughnut can be extended, as needed, to accommodate the height of each commissural post. The tongue for the normal left sinus was removed, and the proximal root anastomosis was carried across the top of the left sinus. The single right coronary ostium was implanted into the graft, and the distal aortic anastomosis was completed. Post-bypass, the leaflets exhibited excellent effective height, and moved well with no residual leak. After valve repair, the mean valve gradient was 7 mmHg.

Key messages:

  • Selective sinus replacement avoids unnecessary sinus resection and coronary reimplantation
  • The HAART 301 Sizers provide an objective measure for evaluating individual sinus dilatation
  • Incorporating the device pledgets into the anastomosis suture line secures the graft to the subvalvular HAART Device and reinforces the root reconstruction
  • Commissure positioning is not determined by the graft. The vertical graft incisions are extended to accommodate the height of each individual commissure
  1. Urbanski, P. P., et al. (2018). “Patient-tailored aortic root repair in adult marfanoid patients: Surgical considerations and outcomes.” J Thorac Cardiovasc Surg 155(1): 43-51.e41.

About BioStable Science & Engineering
BioStable Science & Engineering is a cardiovascular device company focused on developing and commercializing proprietary valve repair technologies that provide an alternative to valve replacement for patients with aortic valve disease. The company’s HAART Aortic Repair Technologies are designed to simplify and standardize aortic valve repair, enabling surgeons to offer the recognized clinical benefits of valve repair to patients undergoing surgical correction of aortic insufficiency or aortic root aneurysm.

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