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J Thorac Cardiovasc Surg 2008;135:1401-1402
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Surgical techniques for posterior aortic root enlargement

Duko Nei, MD, PhD, FETCS, Aleksandar Kneevi, MD, BcS, Saa Borovi, MD

"Dedinje" Cardiovascular Institute, Belgrade, Serbia

To the Editor:

We have read with extreme interest the paper by Dhareshwar and colleagues,¹ published in a recent issue, describing their results with patients undergoing posterior aortic root enlargement.

We absolutely agree that there is still considerable confusion in the literature regarding the techniques proposed by the enlargement techniques described by Nicks, Cartmill, and Bernstein² and by Manouguian and Seybold-Epting,³ as was obvious even in subsequent discussion of the article by Dhareshwar and associates.¹

Although the authors have correctly presented Nicks' posterior aortic root enlargement procedure in a paragraph describing the surgical technique (aortotomy is extended into the noncoronary sinus toward its belly to, but not beyond, the annulus), they have added more embarrassing details with the subsequent description of Figure 2. Let me quote from the legend to Figure 2 from their article:

"Figure 2. A: a, Nicks' aortic root enlargement is accomplished by extending the aortotomy incision across the aortic annulus into the anterior leaflet of the mitral valve. b, Care must be taken to carry this incision posteriorly into the center of the anterior leaflet...."¹

Here is a citation from the original manuscript by Nicks, Cartmill, and Bernstein² concerning the surgical technique:

".....When it is revealed that the aortic annulus is small, aortic incision is carried downwards posteriorly through the non-coronary aortic sinus across the aortic ring as far as the origin of the mitral valve (Figs 2a, b and 3). A tongue of woven Dacron material, cut from a prosthetic tubular arterial graft and with its natural curvature facing the lumen, is sutured down to the fibrous origin of the mitral ring with two mattress sutures...."

Thus, it is obvious that Nicks' method of posterior aortic root enlargement does not include penetration of the incision into the anterior mitral leaflet.

Surgical techniques of posterior aortic root enlargement reported so far are presented schematically in Figure 1. Although Manouguian's technique (the aortic incision is extended through the commissure of the left coronary cusp and noncoronary cusp to the anterior mitral leaflet and the left atrial roof) was correctly reported, we would like to remind the readers of the technique of Nuñez and colleagues⁴ reported back in 1983. After resection of the aortic cusps, the adventitia of the aorta is separated by blunt dissection distally beyond the posterior commissure. Then, the aortic incision is further extended from the top of the noncoronary cusp–left coronary cusp commissure (the same direction as in Manouguian's technique, Figure 1) to just above the confluence of the interventricular fibrous trigone, left atrial wall, and mitral valve annulus, thus avoiding injury and reconstruction of the left atrial roof and anterior mitral leaflet. Furthermore, a patch inserted to enlarge the annulus and to facilitate closure of the aortotomy is attached to firm structures—the fibrous base of the anterior mitral leaflet and the aortic wall. This elegant and safe technique enables insertion of a prosthetic valve possibly two sizes larger in the small aortic root, and long-term survival as well as freedom from valve-related complications are satisfactory (actuarial freedom from death of 88.2% at 15 years has been reported).⁵

View larger version (20K): [in this window] [in a new window]   Figure 1. Surgical techniques of posterior aortic root enlargement reported so far (Nick's-white arrow, Nuñez's-black arrow, Manouquian's-black plus black dotted arrows). NCC, noncoronary cusp; LCC, left coronary cusp; RCC, right coronary cusp; AML, anterior mitral leaflet.

References

1. Dhareshwar J, Sundt III T, Dearani J, Schaff H, Cook D, Orszulak T. Aortic root enlargement: what are the operative risks?. J Thorac Cardiovasc Surg 2007;134:916-924.[Abstract/Free Full Text]
   
2. Nicks R, Cartmill T, Bernstein L. Hypoplasia of the aortic root. The problem of aortic valve replacement. Thorax 1970;25:339-346.[Abstract/Free Full Text]
   
3. Manouguian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet: new operative technique. J Thorac Cardiovasc Surg 1979;78:402-412.[Abstract]
   
4. Nuñez L, Gil Aguado M, Pinto AG, Larrea JL. Enlargement of the aortic annulus by resecting the commissure between the left and noncoronary cusps. Tex Heart Inst J 1983;10:301-303.[Medline]
   
5. Ardal H, Toker ME, Rabus MB, Uyar , Antal A, imanglu M, et al. Does aortic root enlargement impair the outcome of patients with small aortic root?. J Card Surg 2006;21:449-453.[Medline]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sasa Borovic Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Nezic, D. Articles by Borovic, S. Search for Related Content PubMed Articles by Nezic, D. Articles by Borovic, S. Related Collections Education Valve disease