As diagnostic tools continue to advance, more and more aortic diseases are being diagnosed. Among the many aortic diseases, aortic root lesions are the most common. The basis of surgical treatment is widely performed in China.
This article describes several common surgical procedures for aortic root lesions, including the Wheat procedure, Bentall procedure, Carbrol procedure, David procedure, and various procedures for managing supra-aortic stenosis, such as the Ross procedure.
The Wheat procedure is an aortic valve and ascending aortic replacement procedure that preserves the aortic sinus. This procedure was designed and performed by Wheat in 1964 for those who have no significant lesions in the aortic sinus, but cannot preserve the aortic valve and have a significantly dilated ascending aorta.
The procedure is performed as follows: the aortic valve leaflet is removed, the aortic sinus wall surrounding the left and right coronary artery openings is preserved, the rest of the sinus wall is removed, the aortic valve is replaced with an artificial heart valve, and a segment of the artificial vessel is trimmed to the proper shape to replace the diseased ascending aorta.
The advantages of this procedure are that it is not technically difficult, easier to stop bleeding, and relatively easy to generalize.
However, this method also has the following disadvantages.
1. The residual aortic sinus wall may be aneurysmal again, and the patient may need another operation.
2. The proximal aorta has two local anastomoses in close proximity, which may lead to bleeding complications. In view of these disadvantages, the use of the Wheat procedure is decreasing.
Bentall procedure
The Bentall procedure is an aortic root replacement with valve prosthesis + bilateral coronary artery opening graft, which was pioneered by Bentall and DeBono in 1968 at the Hammersmith Hospital in London, England, and has since become the most classic procedure for aortic root lesion surgery.
This approach is suitable for patients with significant dilated aneurysmal aortic root lesions, significant displacement of the bilateral coronary openings, and aortic valves that cannot be repaired by shaping.
The details of the procedure are as follows.
The aneurysmal ascending aorta is incised, the diseased aortic valve is removed, the aortic valve is replaced with a prosthetic vessel with a valve (Figure 1), and two small holes of 0.8-1 cm are incised at the corresponding locations to anastomose the bilateral coronary artery openings on it (Figure 2), and finally the prosthetic vessel with a valve is anastomosed to the distal end of the ascending aorta.
At present, this method is commonly used in China, while abroad, the button-type anastomosis of the coronary artery opening is mostly used, that is, the bilateral coronary arteries are free and trimmed so that the opening is in the shape of a button, and they are anastomosed on the corresponding position of the prosthesis with a valve. This method is widely applicable and can almost replace the Wheat procedure.
This procedure eliminates the occurrence of aortic sinus revascularization, but there are also the following disadvantages: the biggest problem in aortic surgery currently carried out in China is intraoperative bleeding, and if the Button-type anastomosis method is used abroad, it is easy to cause a large amount of intraoperative blood loss in patients, and even an uncontrollable situation with adverse consequences.
Therefore, the method currently used in China is to anastomose the coronary artery directly to the artificial vessel without freeing the opening. This method facilitates hemostasis, allows the residual aneurysm wall to wrap the artificial vessel, and establishes a shunt with the right atrium. However, when using this anastomosis method, care should be taken to close the coronary artery opening with a full suture to avoid pseudoaneurysm.
Cabrol procedure.
In 1981, Cabrol invented the Cabrol procedure by improving on the Bentall procedure. The difference between the two is the method of anastomosis of the left and right coronary artery openings.
The Cabrol procedure is performed as follows.
When the suture of the prosthetic vessel with valve and aortic valve ring is completed, a section of 8~10mm prosthetic vessel is taken and anastomosed with the left and right coronary artery openings respectively, and then this 8~10mm prosthetic vessel is laterally anastomosed with the prosthetic vessel with valve, the tension of the bilateral coronary artery anastomosis is small in this method, and the incidence of bleeding is low, but this 8~10mm prosthetic vessel is more likely to be twisted and deformed, and because the vessel is However, this 8-10 mm prosthetic vessel is more prone to distortion and deformation, and because of the thinness of the vessel, it is easy to form thrombus and affect myocardial blood supply.
David’s surgery.
In 1992, David, a Canadian scholar, proposed aortic root replacement with preservation of the aortic valve, known as the David procedure (commonly used procedures are David type I and David II).
David type I surgery.
The steps of David type I surgery are to excise the aortic root and remove the aortic sinus sinus wall along the aortic annulus 3 mm parallel to the annulus; take the corresponding size artificial vessel without trimming the proximal end, fix the aortic annulus into the artificial vessel, and suspend the 3 valve junctions upward into the artificial vessel; free the left and right coronary artery openings in the shape of a button, and anastomose them to the corresponding position in the artificial vessel.
David type II surgery.
Because the David type I procedure forces the aortic sinus to be pulled up to the same level, postoperative complications such as aortic valve insufficiency are likely to occur David modified it and designed the David type II procedure, which trims the artificial vessels at the ectocardial end into a scallop shape and replaces the corresponding aortic sinus wall respectively.
A French surgeon modified the David II procedure by removing the aortic sinus, measuring the height of the aortic sinus precisely, cutting the artificial vessel into three pieces of corresponding size, trimming them to the corresponding shape of the aortic sinus according to the measured height of the aortic sinus, and performing aortic sinus plication separately. This method is more accurate in reconstructing the aortic sinus and avoiding distortion of the aortic sinus. The author has applied this method in his clinical work and obtained good results.
David’s procedure preserves the patient’s own aortic valve, which can retain its function after surgery and avoid complications such as thrombosis, degeneration, and bleeding after prosthetic heart valve replacement, and the patient has a high quality of life after surgery. However, the successful implementation of this procedure requires very high diagnostic imaging and operator requirements, and postoperative hemostasis is difficult. The authors recommend that this procedure be performed in an experienced cardiovascular surgery center.
There are also Ross procedures for aortic root surgery, which are described in more detail in congenital heart surgery and will not be repeated here.