Aortic-mitral annular enlargement technique in re-valve surgery: A retrospective study in a single center_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

YANG Mingyuan , LIU Wenhao , SONG Laichun , WU Jingcheng ,  TAO Liang

Department of Cardiac Surgery, Wuhan Asia Heart Hospital, Wuhan, 430022, P. R. China;

Corresponding author：

TAO Liang, Email: taoliangmd@sina.com

Keywords：

Annular enlargement; reoperation; small aortic root; prosthesis-patient mismatch

DOI：

10.7507/1007-4848.202210032

Video：

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Objective To investigate and evaluate the safety and efficacy of the aortic-mitral annular enlargement technique (double annular enlargement) in patients with small-size valve prostheses after prior valve surgery. Methods The clinical data of patients who underwent double valve annular enlargement in Wuhan Asia Heart Hospital from April 2020 to April 2022 were retrospectively analyzed. Results A total of 30 patients were collected, including 2 males and 28 females aged 9-78 (52.71±3.53) years. All patients had previous heart valve surgery, including 1 patient receiving the third heart surgery. All patients were operated on successfully and there were no postoperative in-hospital deaths. There was no postoperative bleeding which needed a secondary open-chest hemostasis, and one patient underwent permanent pacemaker implantation due to postoperative sick sinus syndrome. The mean diameter of the implanted prosthetic aortic valve was 24.23±1.60 mm, which was significantly larger than that of the preoperative aortic valve (21.03±1.90 mm, P＜0.001). The mean diameter of the implanted prosthetic mitral valve was 28.33±1.21 mm, which was significantly larger than that of the preoperative mitral valve (25.43±0.84 mm, P＜0.001). The mean peak gradient difference across the prosthetic aortic valve on postoperative echocardiography was 18.17±6.44 mm Hg, which was significantly lower than that of the preoperative aortic valve (82.57±24.48 mm Hg, P＜0.001). The mean peak gradient difference of the postoperative prosthetic mitral valve was 12.73±5.45 mm Hg, which was significantly lower than that of the preoperative mitral valve (19.43±8.97 mm Hg, P=0.003). Conclusion The double annular enlargement technique is safe and effective for reoperation in patients with a history of valve surgery with a small aortic root to obtain both a larger size prosthetic valve for a larger orifice area and stability of the mitral-aortic valve union, resulting in good postoperative hemodynamic characteristics and clinical outcomes.

Citation： YANG Mingyuan, LIU Wenhao, SONG Laichun, WU Jingcheng, TAO Liang. Aortic-mitral annular enlargement technique in re-valve surgery: A retrospective study in a single center. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2024, 31(6): 826-831. doi: 10.7507/1007-4848.202210032 Copy

1.	赵振刚, 陈飞, 陈茂. 心脏瓣膜病的介入治疗进展. 华西医学, 2020, 35(4): 401-405.
2.	李誉, 宋来春, 王波, 等. Bentall手术在小主动脉根部或瓣环再次手术中应用的临床研究. 中国胸心血管外科临床杂志, 2022, 29(5): 592-596.
3.	Ternacle J, Abbas AE, Pibarot P. Prosthesis-patient mismatch after transcatheter aortic valve replacement: Has it become obsolete? JACC Cardiovasc Interv, 2021, 14(9): 977-980.
4.	Furuse A, Mizuno A, Asano K. Aortoatrioplasty with double valve replacement for infective endocarditis. J Cardiovasc Surg (Torino), 1984, 25(5): 462-464.
5.	De Oliveira NC, David TE, Armstrong S, et al. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body: An analysis of clinical outcomes. J Thorac Cardiovasc Surg, 2005, 129(2): 286-290.
6.	Thongcharoen P, Subtaweesin T, Sakiyalak P. Double annulus enlargement, Rastan-Manouguian's technique: A case report. J Med Assoc Thai, 1998, 81(12): 1034-1039.
7.	Kawachi Y, Tominaga R, Tokunaga K. Eleven-year follow-up study of aortic or aortic-mitral anulus-enlarging procedure by Manouguian's technique. J Thorac Cardiovasc Surg, 1992, 104(5): 1259-1263.
8.	Vojacek J, Zacek P, Ondrasek J. Multiple valve endocarditis: A hemi-Commando procedure. Ann Cardiothorac Surg, 2019, 8(6): 705-707.
9.	Navia JL, Elgharably H, Hakim AH, et al. Long-term outcomes of surgery for invasive valvular endocarditis involving the aortomitral fibrosa. Ann Thorac Surg, 2019, 108(5): 1314-1323.
10.	吴竞成, 宋来春, 肖红艳, 等. “衬裙”技术在成人二尖瓣置换中的应用及疗效评价. 中国心血管病研究, 2022, 20(6): 527-530.
11.	Hamandi M, Lanfear AT, Squiers JJ, et al. Double-valve replacement in patients with mitral annular calcification and aortic stenosis. Ann Thorac Surg, 2021, 111(5): e311-e313.
12.	Bahlmann E, Cramariuc D, Minners J, et al. Small aortic root in aortic valve stenosis: Clinical characteristics and prognostic implications. Eur Heart J Cardiovasc Imaging, 2017, 18(4): 404-412.
13.	Niinami H, Aomi S, Tomioka H, et al. A comparison of the in vivo performance of the 19-mm St. Jude Medical hemodynamic plus and 21-mm standard valve. Ann Thorac Surg, 2002, 74(4): 1120-1124.
14.	Singh M, Sethi A, Mishra AK, et al. Echocardiographic imaging challenges in obesity: Guideline recommendations and limitations of adjusting to body size. J Am Heart Assoc, 2020, 9(2): e014609.
15.	Chacko SJ, Ansari AH, McCarthy PM, et al. Prosthesis-patient mismatch in bovine pericardial aortic valves: Evaluation using 3 different modalities and associated medium-term outcomes. Circ Cardiovasc Imaging, 2013, 6(5): 776-783.
16.	Doenst T. Effective orifice area is patient-specific! J Thorac Cardiovasc Surg, 2020, 159(6): e329.
17.	Yang B, Ghita C, Makkinejad A, et al. Early outcomes of the Y-incision technique to enlarge the aortic annulus 3 to 4 valve sizes. J Thorac Cardiovasc Surg, 2024, S0022-5223(22): 1196-1205.
18.	Marey G, Said SM. Combined manouguian-guiraudon approach for double valve replacement: The Commando revisited. Ann Thorac Surg, 2021, 111(2): e139-e141.
19.	Manouguian S, Abu-Aishah N, Neitzel J. Patch enlargement of the aortic and mitral valve rings with aortic and mitral double valve replacement. Experimental study. J Thorac Cardiovasc Surg, 1979, 78(3): 394-401.
20.	David TE. Aortic valve sparing in different aortic valve and aortic root conditions. J Am Coll Cardiol, 2016, 68(6): 654-664.
21.	David TE, Lafreniere-Roula M, David CM, et al. Outcomes of combined aortic and mitral valve replacement with reconstruction of the fibrous skeleton of the heart. J Thorac Cardiovasc Surg, 2022, 164(5): 1474-1484.

1. 赵振刚, 陈飞, 陈茂. 心脏瓣膜病的介入治疗进展. 华西医学, 2020, 35(4): 401-405.
2. 李誉, 宋来春, 王波, 等. Bentall手术在小主动脉根部或瓣环再次手术中应用的临床研究. 中国胸心血管外科临床杂志, 2022, 29(5): 592-596.
3. Ternacle J, Abbas AE, Pibarot P. Prosthesis-patient mismatch after transcatheter aortic valve replacement: Has it become obsolete? JACC Cardiovasc Interv, 2021, 14(9): 977-980.
4. Furuse A, Mizuno A, Asano K. Aortoatrioplasty with double valve replacement for infective endocarditis. J Cardiovasc Surg (Torino), 1984, 25(5): 462-464.
5. De Oliveira NC, David TE, Armstrong S, et al. Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body: An analysis of clinical outcomes. J Thorac Cardiovasc Surg, 2005, 129(2): 286-290.
6. Thongcharoen P, Subtaweesin T, Sakiyalak P. Double annulus enlargement, Rastan-Manouguian's technique: A case report. J Med Assoc Thai, 1998, 81(12): 1034-1039.
7. Kawachi Y, Tominaga R, Tokunaga K. Eleven-year follow-up study of aortic or aortic-mitral anulus-enlarging procedure by Manouguian's technique. J Thorac Cardiovasc Surg, 1992, 104(5): 1259-1263.
8. Vojacek J, Zacek P, Ondrasek J. Multiple valve endocarditis: A hemi-Commando procedure. Ann Cardiothorac Surg, 2019, 8(6): 705-707.
9. Navia JL, Elgharably H, Hakim AH, et al. Long-term outcomes of surgery for invasive valvular endocarditis involving the aortomitral fibrosa. Ann Thorac Surg, 2019, 108(5): 1314-1323.
10. 吴竞成, 宋来春, 肖红艳, 等. “衬裙”技术在成人二尖瓣置换中的应用及疗效评价. 中国心血管病研究, 2022, 20(6): 527-530.
11. Hamandi M, Lanfear AT, Squiers JJ, et al. Double-valve replacement in patients with mitral annular calcification and aortic stenosis. Ann Thorac Surg, 2021, 111(5): e311-e313.
12. Bahlmann E, Cramariuc D, Minners J, et al. Small aortic root in aortic valve stenosis: Clinical characteristics and prognostic implications. Eur Heart J Cardiovasc Imaging, 2017, 18(4): 404-412.
13. Niinami H, Aomi S, Tomioka H, et al. A comparison of the in vivo performance of the 19-mm St. Jude Medical hemodynamic plus and 21-mm standard valve. Ann Thorac Surg, 2002, 74(4): 1120-1124.
14. Singh M, Sethi A, Mishra AK, et al. Echocardiographic imaging challenges in obesity: Guideline recommendations and limitations of adjusting to body size. J Am Heart Assoc, 2020, 9(2): e014609.
15. Chacko SJ, Ansari AH, McCarthy PM, et al. Prosthesis-patient mismatch in bovine pericardial aortic valves: Evaluation using 3 different modalities and associated medium-term outcomes. Circ Cardiovasc Imaging, 2013, 6(5): 776-783.
16. Doenst T. Effective orifice area is patient-specific! J Thorac Cardiovasc Surg, 2020, 159(6): e329.
17. Yang B, Ghita C, Makkinejad A, et al. Early outcomes of the Y-incision technique to enlarge the aortic annulus 3 to 4 valve sizes. J Thorac Cardiovasc Surg, 2024, S0022-5223(22): 1196-1205.
18. Marey G, Said SM. Combined manouguian-guiraudon approach for double valve replacement: The Commando revisited. Ann Thorac Surg, 2021, 111(2): e139-e141.
19. Manouguian S, Abu-Aishah N, Neitzel J. Patch enlargement of the aortic and mitral valve rings with aortic and mitral double valve replacement. Experimental study. J Thorac Cardiovasc Surg, 1979, 78(3): 394-401.
20. David TE. Aortic valve sparing in different aortic valve and aortic root conditions. J Am Coll Cardiol, 2016, 68(6): 654-664.
21. David TE, Lafreniere-Roula M, David CM, et al. Outcomes of combined aortic and mitral valve replacement with reconstruction of the fibrous skeleton of the heart. J Thorac Cardiovasc Surg, 2022, 164(5): 1474-1484.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Aortic-mitral annular enlargement technique in re-valve surgery: A retrospective study in a single center

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