Minimally invasive aortic valve replacement with Freestyle Aortic Root Bioprosthesis (Freestyle Bioprosthesis, Medtronic, Inc.) in 22 year-old female with severe aortic insufficiency and progressive left ventricular dilation, using a "mini-root" technique with coronary artery reimplantation.
HistoryThis patient was first seen in 1992 at age 17 after being treated for four weeks with IV antibiotics for endocarditis from which she developed severe valvular insufficiency. At that time she showed no symptoms and minimal left ventricular dilation and, thus, was treated medically. She was advised that aortic valve replacement surgery would eventually be necessary and the Ross Procedure was discussed as a possible option. After 5 years of medical treatment with afterload reduction therapy she was seen in November, 1997, for signs of progressive deterioration of ventricular function, which was noted on her serial echocardiographic examination. The echocardiographic study revealed progressive left ventricular dilation, with an end-diastolic dimension of 6 cm, and early left ventricular systolic dysfunction, although she remained asymptomatic.
The various surgical options and prosthetic devices were reviewed with the patient and her parents, including the Ross procedure, mechanical valve options, and newer bioprosthetic valve options. The patient and her family expressed concerns over any valve that would require long-term anticoagulation during the child bearing years, but also wanted a valve that would provide optimal hemodynamic performance, as she had an active, athletic life style. She was also concerned about the cosmetic aspects of the surgery. Thus, if feasible, she wanted a minimally invasive approach with a non-conspicuous chest incision. A small transverse sternotomy incision was selected as the operative approach in order to minimize scarring and produce the best cosmetic result in this attractive 22 year-old female, while allowing for "mini-root" replacement to implantation of the Freestyle Bioprosthesis (Medtronic, Inc.). This bioprosthesis was selected both for its good flow characteristics and for the potential long-term benefits of the AOL anti-calcification processing. This valve also offered the best hemodynamics for a bioprosthesis, yet also presumably gave the best chance for excellent late durability, without the need for anticoagulant therapy. This choice of bioprosthesis also avoided the more extensive Ross operation, which would require full sternotomy and the replacement of two valves.
Operative ProcedureThe operation was performed on December 23, 1997. A small transverse sternotomy incision was made over the third intercostal space. Central cannulation was utilized for the introduction of cardiopulmonary bypass, with direct aortic cross-clamping and delivery of cardioplegia by direct coronary ostia cannulation. The aortic valve and aortic root were excised totally, leaving the coronary ostia on small buttons of aortic wall. Pledgeted mattress sutures were used to secure the bioprosthetic sewing ring to the aortic annulus and the coronary arteries were re-implanted with continuous 5-0 cardiovascular suture. The bioprosthetic "mini-root" was sutured end-to-end to the native aorta, just distal to the sinotubular junction. The crossclamp time was 80 minutes and bypass time 120 minutes; one unit of autologous blood was utilized.
Clinical CourseShe was extubated 6 hours postoperatively and did not require exogenous blood transfusion. Intraoperative transesophogeal echocardiogram and post-operative transthoracic echocardiogram both revealed an excellent hemodynamic result, without any significant transvalvular gradient or valvular insufficiency. She reported minimal post-operative pain, with her primary perioperative complaint being discomfort caused by the endotracheal tube. Plans for early discharge were delayed by two days to allow for resolution of a small pericardial effusion. The patient was able to return to work and normal daily activity two weeks post-operatively. By echocardiographic evaluation her ventricular systolic and diastolic dimensions returned to normal. She has a normal exercise capacity, without limitations and is extremely pleased with the cosmetic result. Her only medication is Ecotrin.