Regurgitation through a stentless prosthesis treated with aortic root banding

Abstract

Clinical Summary A 71-year-old woman presented with mixed aortic valve disease. She underwent aortic valve replacement with a size 27 Elan stentless valve (scalloped porcine prosthesis, Aortech Europe Ltd) implanted in a subcoronary position. The ascending aorta was noticed to be thin. The operation and postoperative recovery were uneventful. Echocardiography at discharge revealed moderate central prosthetic regurgitation, with dilatation of the STJ (from 30 to 32 mm) but not the annulus. The left ventricular end-diastolic diameter (LVEDD), however, was reduced (from 55 to 48 mm), with improved left ventricular ejection fraction. The patient reported great symptomatic improvement on her 2-month follow-up. A repeat echocardiogram 11 months after the operation was unchanged. The patient had significant symptomatic deterioration 13 months after the operation, with clinical signs of heart failure. Echocardiography confirmed severe regurgitation, with an increase in LVEDD to 54 mm and STJ to 34 mm, but the annulus diameter was unchanged. In view of this, a further operation was undertaken. At the time of the operation, the ascending aorta was separated from the pulmonary artery. A 5-cm-wide polytetrafluoroethylene strip was applied tightly around the STJ and the ascending aorta, reducing the diameter of the former from 34 to 30 mm. This Teflon corset sat just distal to the coronary artery origins and the sinuses of Valsalva. This abolished the regurgitation on transesophageal echocardiography. The valve was well seated and opened well, with a normal gradient. The leaflets appeared normal. Both edges of the strip were secured to each other with the suture, including the aortic adventitia, thereby fixing the band in position and avoiding its distal migration (Figure 1). Postoperatively, the patient recovered uneventfully. Predischarge echocardiography showed trivial aortic regurgitation, with reduction of LVEDD to 48 mm (Figure 2). Six months after the operation, the patient was asymptomatic, and the echocardiogram was unchanged.