Title: Trans-cuff leakage in bio-Bentall operation
Running title: Trans-cuff leakage in bio-Bentall operation
Authors: Azumi Hamasaki, MD, PhD, Kozo Morita, MD, Masahiro Ikeda, MD,
Hiroshi Niinami, MD, PhD
Institution: Department of Cardiovascular Surgery, Tokyo Women’s Medical
University, 8-1 Kawada-cho, Shinjuku 162-8666, Japan
Funding: none declared.
Corresponding author: Azumi Hamasaki
Department of Cardiovascular Surgery, Tokyo Women’s Medical University,
8-1 Kawada-cho, Shinjuku 162-8666, Japan
Tel.: +81-3-3353-8111, Fax: +81-3-3356-0441
E-mail:hamasaki-ths@umin.ac.jp
Abstract
We have reported a case of trans-cuff leakage that occurred in a
composite graft of bio-Bentall operation. The leakage resolved several
months after surgery, similar to the trans-cuff leakage seen in simple
aortic valve replacement. We have proposed hypotheses on the mechanism
of trans-cuff leakage during a bio-Bentall operation and suggested ways
to prevent it from occurring.
Keywords: trans-cuff leakage, bioprosthesis, Bentall operation
Introduction
Aortic root replacement is a widely performed operation for diseased
aortic root involving aortic valve insufficiency and sinus of Valsalva
dilatation. Valve-sparing aortic root replacement is recommended for
younger patients, while aortic root replacement using a bioprosthetic
valve [1], so called ‘bio-Bentall operation’ is still the standard
procedure for elder patients. Recently, with the improvement in the
durability of bioprostheses, the indications for bio-Bentall operation
have expanded.
A composite graft combined with a mechanical valve and a tube graft is
commercially available; however, a composite graft of bio-Bentall
operation needs to be hand sewn. The INSPIRIS RESILIA Aortic Valve
(Edwards Lifesciences, Irvine, CA, USA) is a newly developed
bioprosthesis, which is designed based on the Carpentier Edwards
PERIMOUNT (CEP) Magna Ease aortic bioprosthesis (Edwards Lifesciences).
This series of bioprostheses has a long history of excellent
haemodynamics, but can cause trans-cuff leakage from the stent post due
to its structural features. Trans-cuff leakage during aortic valve
replacement (AVR) has been previously reported [2, 3], but none have
reported trans-cuff leakage in composite grafts of bio-Bentall
operation.
Case Report
A 68-year-old man with a dilated sinus of Valsalva and moderate aortic
regurgitation underwent bio-Bentall operation. The sinus of Valsalva was
49 mm in diameter and the sino-tubular junction was 40 mm in diameter.
The composite graft was prepared by hand sewing a 27-mm INSPIRIS RESILIA
valve into a 30-mm Gelweave Valsalva (Vascutek Ltd., Inchinnan, UK) with
a running 2-0 braided polyester suture. More specifically, the
bioprosthesis was placed on top of the collar under the skirt of the
graft. The composite graft was implanted supra-annularly with 2-0
pledgetted braided polyester non-everting mattress sutures. The threads
were not applied to the sewing-cuff of the bioprosthesis, but it was
applied to the graft collar. Finally, the edge of the graft collar and
remnant of the Valsalva wall were sutured with a running 4-0
polypropylene suture to reinforce and the proximal anastomosis was
completed. Reimplantation of the coronary ostia and distal anastomosis
were performed in the standard fashion. Intra-operative transesophageal
echocardiography (TEE) showed mild leakage blowing vertically from the
sewing-cuff just below the left–right stent post (Figure 1 and Video
1). We judged the leakage to be trans-cuff leakage, which occasionally
occurs in this particular bioprosthesis, and proceeded to complete the
operation. Trivial trans-cuff leakage was noted on transthoracic
echocardiography (TTE) performed 11 days postoperatively, and the
patient was discharged. Trans-cuff leakage disappeared completely on TTE
performed 6 months postoperatively.
Comment
There has been a long-standing concern among surgeons whether to
follow-up or reintervene when intra-operative TEE reveals suspected
perivalvular leakage. Our perception has changed since learning that
trans-cuff leakage occasionally occurs in this particular bioprosthesis
and most eventually resolves within 3 months [3]. This knowledge has
guided our current practice to avoid unnecessary intervention.
In simple AVR, trans-cuff leakage occurs from the left–right commissure
due to the anatomical features of the aortic annulus [3]. The nadir
of the non-coronary cusp is usually at the lowest level compared to the
remaining cusps, and when the CEP Magna Ease aortic bioprosthesis is
secured at the nadir of the non-coronary cusp and implanted obliquely,
the stent post of the left–right commissure is placed at a higher
level. As a result, the weak point of the sewing-cuff may be stretched
at the left–right commissure.
As in the present case, it is unclear why trans-cuff leakage occurs when
the bioprosthesis is fixed to an artificial graft. In our case, we sewed
suture threads from the outside of the graft at the middle of the graft
to fix the bioprosthesis. The sewing-cuff must be sewn out of sight
because the bioprosthesis was sewn in the middle and not at the edge of
the graft. As a result, the depth of the sutures was uneven. In addition
to the anatomical cause of trans-cuff leakage, Hiraoka et al. pointed
out that applying stitches to the edges of the sewing-cuff increases the
risk of leakage [3]. Trans-cuff leakage may have occurred because
the sewing-cuff was sewn shallowly near the stent post, and the weak
point of the sewing-cuff was stretched.
The ideal way to prevent trans-cuff leakage in a hand sewn composite
graft of bio-Bentall operation is to sew the sewing-cuff at a uniform
depth. When the bioprosthesis is sutured at the end of the graft, as in
the double sewing ring technique [4], the sewing-cuff of the
bioprosthesis is clearly visible during the procedure and the sewing
needle can be passed through at a uniform depth; thus, trans-cuff
leakage can be prevented. We have used this technique in several recent
bio-Bentall operations, and no trans-cuff leakages have been reported.
Acknowledgments
We would like to thank Editage (www.editage.com) for English language
editing.
Conflict of interest
The authors declare that they have no conflict of interest.
Patient consent statement
A written informed consent was obtained from the patient.
Ethics statement
The need for ethics approval was waived by the institutional review
board.
Author contributions: KM, AH and MI performed the surgical procedure and
perioperative management. AH collected the data, drafted and critically
revised the manuscript. All authors approved the article. HN supervised
the study.
References
- Etz CD, Homann TM, Rane N, et al. Aortic root reconstruction with a
bioprosthetic valved conduit: a consecutive series of 275 procedures.
J Thorac Cardiovasc Surg 2007;133:1455-63.
- Tokunaga S, Cho T, Izubuchi R, Masuda M. Cuff leakage, not
paravalvular leakage, in the Carpentier Edwards PERIMOUNT Magna Ease
aortic bioprosthesis. Interact Cardiovasc Thorac Surg 2015;21:796-7.
- Hiraoka A, Hayashida A, Totsugawa T, et al. Transprosthetic cuff
leakage of a bovine pericardial aortic bioprosthesis. Semin Thorac
Cardiovasc Surg 2019;31:773-9.
- Albertini A, Dell’Amore A, Zussa C, Lamarra M. Modified Bentall
operation: the double sewing ring technique. Eur J Cardiothorac Surg
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Legends
Figure 1
Intra-operative transesophageal echocardiography showing mild leakage
from the left–right stent post and the regurgitation jet blowing
vertically from the sewing-cuff.
Video 1
Intra-operative transesophageal echocardiography showing the
regurgitation jet from the left–right stent post blowing vertically
from the sewing-cuff.