https://orcid.org/0000-0002-8057-9555
Abstract
We present a modified technique of Hemispherical Aortic Annuloplasty Reconstructive Technology (HAART) 200 annuloplasty ring implantation in bicuspid aortic valve morphology by external fixation of the looping sutures to avoid common complications associated with the original implantation technique. Preliminary results are promising and should be confirmed in subsequent multicentre studies.
INTRODUCTION
Aortic annuloplasty using the internal Hemispherical Aortic Annuloplasty Reconstructive Technology (HAART) 200 ring (Corcym, Milan, Italy) enabled a standardization of bicuspid aortic valve repair, making it more reproducible and independent of valve morphotype [1]. The original device implantation technique includes subcommissural sutures fixing the commissural posts in a subannular position, followed by looping sutures to stabilize the device that are advanced in the corresponding aortic sinus 2–3 mm behind the hinge point of the aortic cusps [2–5]. Limitations of this implantation technique include an increased complication risk due to extensive cusp manipulation and looping suture tails [6, 7]. Therefore, alterations of the original implantation technique have been proposed [8]. Herewith, we present our modified implantation technique, including external fixation of all looping sutures.
SURGICAL TECHNIQUE
Video material is provided to illustrate modifications of the original implantation technique. Video 1 shows the preoperative diagnostics of the patient (see Supplementary Material, Table S1 for our institutional policy for selection of aortic annuloplasty technique). After mini-sternotomy, establishment of cardiopulmonary bypass, transverse aortotomy and valve exposure by commissural traction sutures, sizing of the HAART 200 device is performed in standard fashion [3]. Now, an external dissection of the aortic root is performed down to the annulus level without detaching the coronary ostia, similar as required for external aortic annuloplasty. Next, the HAART 200 device is brought into the surgical field. Two subcommissural sutures are accomplished in a standard fashion [3]. The device is lowered down and positioned properly in the subannular compartment. Then, transannular looping sutures are placed using 2–0 Ethibond with V6 or V7 needles (Ethicon, Inc., Somerville, NJ, USA). The first needle is placed 2 mm below the cusp insertion point from the inside of the left ventricular outflow tract (LVOT) above the annuloplasty device and forwarded to the outside of the aorta. The second needle is placed from the inside of the LVOT below the device and forwarded similarly to the outside of the aorta. Three to four looping sutures are placed in the non-coronary sinus and 4 looping sutures in the area of the fused right–left coronary sinus. The subannular area between the mid-part of the right-coronary sinus and the right–non-coronary commissure is spared to minimize the risk of atrioventricular block. After all looping sutures have been positioned, 2 strips of Teflon felt (∼20–25 mm in length) are used as external support for the externalized looping sutures in the non-coronary area and between both coronary ostia. The subcommissural sutures are tied first to enable a geometric 180-degree commissural orientation. Now, the looping sutures are tied over the Teflon felt to prevent them from tearing through the fragile LVOT tissue (Video 2). After non-coronary sinus replacement, cusp manoeuvres are performed as usual, aiming to recreate an effective cusp height of 8–10 mm. Ascending aortic pathology is treated as required (Video 3). Surgical repair result is verified by transoesophageal echocardiography (Video 4). Figure 1 summarizes the modified implantation technique.
Summary of the modified HAART 200 device implantation technique: transannular fixation of the looping sutures at the outside of the aorta, sparing the subannular area below both coronary ostia and the region of the left bundle branch (red arrows) and the use of Teflon as support for the externalized looping sutures in the non-coronary area and between both coronary ostia (blue strips). HAART: Hemispherical Aortic Annuloplasty Reconstructive Technology.
Asymmetric BAV (right/left fusion) with eccentric aortic regurgitation and cardiomyopathy with left ventricular dilation and severely reduced ejection fraction as well as ascending aorta aneurysm (53×52 mm) and root ectasia with predominant dilation of the non-coronary sinus. BAV: bicuspid aortic valve.
Aortic annuloplasty using the HAART 200 device with modified, external fixation of the looping sutures over a Teflon felt. HAART: Hemispherical Aortic Annuloplasty Reconstructive Technology.
Non-coronary sinus replacement, standard cusp repair and supracoronary ascending aorta replacement.
Postoperative transoesophageal echocardiography: symmetric competent BAV. BAV: bicuspid aortic valve.
PRELIMINARY RESULTS
We reviewed all consecutive patients with bicuspid aortic valve repair using the HAART 200 device (n = 19) since August 2022 (Table 1). The original implantation technique was applied in the first 6 patients. In September 2023, the modified technique was introduced and exclusively used thereafter (n = 13). Complications (i.e. atrioventricular block, iatrogenic ventricular septal defect, aortic cusp perforation, or a combination) were reported in 50% of original implantation technique patients, whereas none of the modified technique patients experienced any complication (P = 0.021). See Supplementary Material, Table S2 for more detailed information on original implantation technique-associated complications and their treatment.
Preliminary results
| Original technique (n = 6) | Modified technique (n = 13) | P-value | |
|---|---|---|---|
| Cardiopulmonary bypass time (min) | 131 (45) | 113 (45) | 0.966 |
| Aortic cross-clamp time (min) | 97 (35) | 89 (28) | 0.966 |
| Peak AV gradient at discharge (mmHg) | 16 (10) | 14 (12) | 0.494 |
| Mean AV gradient at discharge (mmHg) | 9 (7) | 7 (6) | 0.213 |
| Residual aortic regurgitation at discharge | 0 (0%) | 0 (0%) | 1.000 |
| Number of patients with complications | 3 (50%) | 0 (0%) | 0.021 |
| Complications | |||
| Complete atrioventricular block | 2 (33%) | 0 (0%) | 0.088 |
| Iatrogenic ventricular septal defect | 2 (33%) | 0 (0%) | 0.088 |
| Basal anterior mitral leaflet perforation | 0 (0%) | 0 (0%) | 1.000 |
| Aortic cusp perforation | 1 (17%) | 0 (0%) | 0.316 |
| Re-do AV surgery | 1 (17%) | 0 (0%) | 0.316 |
| Original technique (n = 6) | Modified technique (n = 13) | P-value | |
|---|---|---|---|
| Cardiopulmonary bypass time (min) | 131 (45) | 113 (45) | 0.966 |
| Aortic cross-clamp time (min) | 97 (35) | 89 (28) | 0.966 |
| Peak AV gradient at discharge (mmHg) | 16 (10) | 14 (12) | 0.494 |
| Mean AV gradient at discharge (mmHg) | 9 (7) | 7 (6) | 0.213 |
| Residual aortic regurgitation at discharge | 0 (0%) | 0 (0%) | 1.000 |
| Number of patients with complications | 3 (50%) | 0 (0%) | 0.021 |
| Complications | |||
| Complete atrioventricular block | 2 (33%) | 0 (0%) | 0.088 |
| Iatrogenic ventricular septal defect | 2 (33%) | 0 (0%) | 0.088 |
| Basal anterior mitral leaflet perforation | 0 (0%) | 0 (0%) | 1.000 |
| Aortic cusp perforation | 1 (17%) | 0 (0%) | 0.316 |
| Re-do AV surgery | 1 (17%) | 0 (0%) | 0.316 |
Data are presented as median (IQR) or absolute (relative) frequencies. P-values are derived from Mann–Whitney U-test and Fisher’s exact test.
AV: aortic valve.
Preliminary results
| Original technique (n = 6) | Modified technique (n = 13) | P-value | |
|---|---|---|---|
| Cardiopulmonary bypass time (min) | 131 (45) | 113 (45) | 0.966 |
| Aortic cross-clamp time (min) | 97 (35) | 89 (28) | 0.966 |
| Peak AV gradient at discharge (mmHg) | 16 (10) | 14 (12) | 0.494 |
| Mean AV gradient at discharge (mmHg) | 9 (7) | 7 (6) | 0.213 |
| Residual aortic regurgitation at discharge | 0 (0%) | 0 (0%) | 1.000 |
| Number of patients with complications | 3 (50%) | 0 (0%) | 0.021 |
| Complications | |||
| Complete atrioventricular block | 2 (33%) | 0 (0%) | 0.088 |
| Iatrogenic ventricular septal defect | 2 (33%) | 0 (0%) | 0.088 |
| Basal anterior mitral leaflet perforation | 0 (0%) | 0 (0%) | 1.000 |
| Aortic cusp perforation | 1 (17%) | 0 (0%) | 0.316 |
| Re-do AV surgery | 1 (17%) | 0 (0%) | 0.316 |
| Original technique (n = 6) | Modified technique (n = 13) | P-value | |
|---|---|---|---|
| Cardiopulmonary bypass time (min) | 131 (45) | 113 (45) | 0.966 |
| Aortic cross-clamp time (min) | 97 (35) | 89 (28) | 0.966 |
| Peak AV gradient at discharge (mmHg) | 16 (10) | 14 (12) | 0.494 |
| Mean AV gradient at discharge (mmHg) | 9 (7) | 7 (6) | 0.213 |
| Residual aortic regurgitation at discharge | 0 (0%) | 0 (0%) | 1.000 |
| Number of patients with complications | 3 (50%) | 0 (0%) | 0.021 |
| Complications | |||
| Complete atrioventricular block | 2 (33%) | 0 (0%) | 0.088 |
| Iatrogenic ventricular septal defect | 2 (33%) | 0 (0%) | 0.088 |
| Basal anterior mitral leaflet perforation | 0 (0%) | 0 (0%) | 1.000 |
| Aortic cusp perforation | 1 (17%) | 0 (0%) | 0.316 |
| Re-do AV surgery | 1 (17%) | 0 (0%) | 0.316 |
Data are presented as median (IQR) or absolute (relative) frequencies. P-values are derived from Mann–Whitney U-test and Fisher’s exact test.
AV: aortic valve.
DISCUSSION
The HAART 200 device is reluctantly used in clinical practice. Limitations commonly brought up are mostly associated with the intra-aortic placement of the looping sutures that can be technically demanding. Furthermore, there is a risk of contact between suture knots and cusp tissue, potentially leading to cusp perforation. Moreover, the looping sutures in the right-coronary sinus adjacent to the right–non-coronary commissure carry a risk of atrioventricular block. Finally, device detachment due to aortic sinus perforation into the LVOT, leading to aorto-left ventricular fistula, has been reported [6, 7]. Considering the sobering complications encountered in our first 6 patients in whom the original implantation technique was applied that could not exclusively be attributed to a learning curve and considering technical adjustments proposed by Jasinski et al. [8], we modified the original implantation technique by introducing an external, transannular fixation of all looping sutures and sparing the subannular area below both coronary ostia and the region of the left bundle branch.
CONCLUSION
Our modified technique of HAART 200 device implantation using an external fixation of the looping sutures shows potential to prevent complications associated with the original implantation technique.
SUPPLEMENTARY MATERIAL
Supplementary material is available at EJCTS online.
FUNDING
No external funding.
Conflict of interest: none declared.
DATA AVAILABILITY
The data underlying this article will be shared on reasonable request to the corresponding author.
Reviewer information
European Journal of Cardio-Thoracic Surgery thanks Jan Vojacek and the other anonymous reviewers for their contribution to the peer review process of this article.
