How-I-Do-It: Aortic Annular Enlargement - Are the Nicks and Manouguian Obsolete?

The Y-incision aortic annular enlargement (AAE), first performed in August 2020, offers a safe and more effective alternative for management of a small aortic annulus/root without need for violation of the left ventricular outflow tract, mitral valve geometry, or left/right atria in both first-time aortic valve replacement (AVR) and reoperative AVR. In the first consecutive 119 patients with Y-incision AAE, the median age was 65 (59, 71), 67% female, 28% had previous cardiac surgery, and 2 cases had endocarditis. The preoperative mean gradient was 36 (30, 47), and the native aortic valve area was 0.9 (0.7, 1.0). After aortic annular enlargement, the median prosthesis size was 29 (27, 29) with 63% of patients having a size 29 or the largest sized valve. The median increment of annulus enlargement was 3 (3, 4) valve sizes. Postoperative complications included 1 operative mortality, 1 stroke exacerbation, and 2 pacemaker implantations (including one case of endocarditis with Gerbode fistula). There was no renal failure requiring permanent dialysis, mediastinitis, or reoperation for bleeding. Postoperative computed tomography aortogram showed the aortic root was enlarged from 27 (24, 30) to 40 (37, 42) mm without aortic pseudoaneurysm. The postoperative mean gradient was 6 (5, 9) mm Hg and valve area was 2.2 (1.8, 2.6) cm2 at 24 months. Mitral and tricuspid valve functions were significantly improved. This report describes the Y-incision technique with the most up-to-date modifications and short-term outcomes.

Comparison of the short-term outcomes between Y-incision aortic annular enlargement and traditional aortic annular enlargement techniques.

Background: The short-term efficacy and safety of the Y-incision technique of aortic annular enlargement (AAE) has been established. We aimed to determine how the short-term outcomes of the Y-incision technique compared to traditional AAE techniques. Methods: From February 2011 to June 2022, 380 patients at the University of Michigan Hospital underwent aortic valve replacement (AVR) with AAE using either traditional annular enlargement techniques (Traditional group, n=270), including Nicks [63% (171/270)], Manouguian [34% (91/270)], and others [3% (8/270)], or the Y-incision technique (Y-incision group, n=110). Propensity score matching was performed by controlling for age, sex, body surface area (BSA), hypertension, diabetes, dialysis, chronic lung disease, stroke, prior cardiac surgery, primary indication, operative status, concomitant procedures, and prosthesis type, to generate a balanced cohort of 103 pairs. Results: There were no differences in demographics, comorbidities, primary indications of the operations, or concomitant procedures between the matched groups. The median native aortic annulus diameter, measured in the operating room, was 21 mm for both groups. Median prosthesis size was 23 in the Traditional group, and 27 in the Y-incision group (P<0.001). There were no differences in perioperative complications/outcomes between the matched groups, including operative mortality, which was 3.9% (8/206) overall. Short-term survival was similar between the groups on Kaplan-Meier analysis; one-year survival was 95% in the Traditional group, and 97% in the Y-incision group (P=0.54). The Y-incision group had significantly lower mean aortic valve gradients (7 vs. 10 mmHg, P<0.001), larger aortic valve areas (2.2 vs. 1.8 cm2, P=0.007), and less moderate/severe patient-prosthesis mismatch (PPM) (5.5% vs. 23%, P=0.039) on one-year follow-up echocardiography. Conclusions: The Y-incision technique was as safe and more effective in enlarging the aortic annulus and upsizing the prosthetic valve than the traditional techniques of AAE in AVR for small aortic annuli.

Late Outcomes of Konno-Rastan and Modified Konno for Left Ventricular Outflow Tract Obstruction.

BACKGROUND: While early outcomes of the Konno-Rastan and modified Konno procedures are known, long-term outcomes remain undetermined. Our objective was to examine long-term clinical and echocardiographic outcomes. METHODS: Retrospective review was performed of patients undergoing Konno-Rastan and modified Konno for complex left ventricular outflow tract (LVOT) obstruction from January 1980 to January 2021. The Ross-Konno procedure was excluded due to its often limited ventriculotomy. RESULTS: A total of 92 patients were identified: 73 Konno-Rastan and 19 modified Konno. The modified Konno group was significantly younger (median [interquartile range, IQR]: 6, [2-12] years vs 16 [9-32] years, P = .001). LVOT obstruction was multilevel (39 of 92 [42.4%]), tunnel subaortic (35 of 92 [38.0%]), or aortic valve stenosis/annular hypoplasia (18 of 92 [19.6%]). Shone syndrome was present in 20 of 92 (21.7%) patients. Operative mortality was 7 of 92 (7.6%); 4 of 86 (4.7%) in elective vs 3 of 6 (50.0%) in urgent cases (P = .005). Median follow-up was 12 (IQR, 5-22) years. Aortic valve/LVOT mean gradient was 13 (IQR, 10-18) mm Hg at 1 year but gradually increased to 25 (IQR, 13-46) mm Hg at 10 years. Ejection fraction remained normal. Freedom from reoperation at 5 and 10 years was 77.2% and 58.4% among Konno-Rastan and 57.7% and 41.7% among modified Konno patients (P = .28), respectively. Overall survival at 5, 10, and 15 years was 82.9%, 76.3%, and 65.5%. Risk factors for mortality included older age, New York Heart Association class III/IV, longer cardiopulmonary bypass time, and multilevel LVOT obstruction. CONCLUSIONS: While LVOT obstruction is alleviated early, recurrent LVOT obstruction occurs over time after Konno-Rastan and modified Konno procedures. Additionally, despite preserved left ventricular systolic function, late overall survival is poor in this young population.

Intra-atrial Pulmonary Venous Conduit Leak in Criss-Cross Heart: Role of Three-Dimensional Modeling.

Three-dimensional (3D) modeling has become an invaluable tool for operative planning in the continually evolving complex field of adult congenital heart surgery. We present a case of an intra-atrial conduit leak after multiple repairs of common atrium and criss-cross morphology. 3D modeling was critical in preoperative evaluation and operative planning for complicated intracardiac anatomy after an uncommon initial approach to preserve a biventricular circulation. In the setting of complex or rare congenital cardiac anomalies, advanced imaging and 3D modeling are helpful with preoperative planning.

Pulmonary Artery Sarcoma Complete Resection Facilitated by 3-Dimensional Printed Model.

Primary pulmonary artery sarcomas are rare tumors and are commonly misdiagnosed as pulmonary embolism. Primary pulmonary sarcomas demonstrate intraluminal growth into the vessel, rather than through the wall; require complete resection to enhance survival; and require complex surgical planning. The purpose of this case report is to describe an optimal team approach with multidisciplinary planning facilitated by a customized 3-dimensional model to guide intervention and enhance communication.

Atlanto-Occipital Transarticular Screw Fixation for the Treatment of Traumatic Occipitocervical Instability in the Pediatric Population.

BACKGROUND: Atlanto-occipital transarticular screw fixation (AOTSF) has rarely been reported for fixation of the craniovertebral junction (CVJ). METHODS: A retrospective chart review of all pediatric patients (less than 18 years of age) with an attempt of AOTSF for fixation of traumatic CVJ instability was conducted. RESULTS: A total of 4 patients (2 boys and 2 girls; ages 2, 3, 5, and 8 years) who suffered from acute traumatic CVJ instability managed during 2007-2018 underwent an attempted AOTSF. In 2 patients, this method was technically successful. In the other 2 instances, we were not able to engage the screw into the occipital condyle. These were converted to standard occipital plate, rod, and screw fixation. All were placed in a halo subsequently for a minimum of 3 months. Three patients were fused at last follow-up (range, 17-48 months). One patient after successful AOTSF did not fuse. There were no surgical complications or revision procedures. CONCLUSIONS: AOTSF was feasible in half of pediatric patients suffering from traumatic CVJ instability. Therefore, intraoperative salvage options and strategies should be on hand readily. In the pediatric population, where bony anatomy may pose challenges to fixation, this technique may offer a viable first-line option in selected cases, despite the overall modest success rate.

Review of Operative Treatment of Delayed Presentation of Acute Cholecystitis.

Treatment of patients with delayed acute cholecystitis (AC) includes antibiotics and interval cholecystectomy based on proposed change at 72 hours from symptom onset to a chronic fibrotic phase with concern for increased complication rates. The purpose of our study was to compare the outcomes of patients undergoing laparoscopic cholecystectomy (LC) for AC before and after this golden 72-hour window. After institutional review board approval, a retrospective study was performed of patients presenting over two years with AC, who underwent LC during the index admission. A chart review was performed, and patients were divided into symptoms <72 hours (group A) and symptoms >72 hours (group B). Complications were defined as postoperative bleeding, return to operating room, and bile leaks. One hundred and eighty-four patients met the study criteria. Group A included 96 patients managed 5 to 71 hours after symptom onset, whereas Group B encompassed 88 patients with symptoms 72 to 336 hours. Both groups had similar baseline demographics and disease severity. No statistically significant differences were noted between the groups regarding overall complications or 30-day morbidity; however, Group B had an increased hospital stay length (P < 0.0001) and estimated blood loss(P = 0.028). LC seems safe despite duration of symptomatology and should be considered during the index admission in all AC patients.