By Charles Abraham Yankah, Yu-Guo Weng, Roland Hetzer
The surgical result of bioprosthetic aortic valve alternative within the Sixties and Seventies weren't very passable. the quest for the suitable alternative for the diseased aortic valve led Donald Ross to advance the concept that of the aortic allograft in 1962 and the pulmonary autograft in 1967 for subcoronary implantation, and later, in 1972, as an entire root for exchanging the aortic root within the contaminated aortic valve with a root abscess. The aortic al- graft and pulmonary autograft surgeries have been revo- tionary within the background of cardiac valve surgical procedure within the final m- lennium simply because they compete good with the bioprosthesis, are nonthrombogenic (thus, requiring no postoperative anticoa- lation), are proof against an infection, fix the anatomic devices of the aortic or pulmonary outflow tract, and supply unimpeded blood circulate and ideal hemodynamics, giving sufferers a b- ter analysis and caliber of lifestyles. surgical procedure for congenital, degenerative, and inflammatory aortic valve and root ailments has now reached a excessive point of adulthood; but a terrific valve for valve substitute isn't on hand. The- fore, surgeons are focusing their abilities and their medical and s- entific wisdom on optimizing the technical artistry of val- sparing tactics.
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Extra resources for Aortic Root Surgery: The Biological Solution
At present, we should restrain from including younger low-risk patients and strictly adhere to established inclusion criteria and to the recently published guidelines . A suitable criteria for high risk is age > 75 and a logistic EuroSCORE > 20% and/or a STS score > 10%. Beside age and risk scores, there are several clinical scenarios where a transcatheter approach might be beneficial: z patients with patent bypass grafts, z patients presenting with porcelain aorta, z patients suffering from end-stage liver failure, z history of chest radiation or mediastinitis.
However, the main improvement of the introduction of the 18 French delivered CoreValve prosthesis is the implantation through a 18 French sheath, and at the end of the procedure the access site is sutured down by means of four prepositioned Prostar sutures (Prostar XL system), a well-known and long-practiced interventional technique . This way, nowadays the procedure is purely interventional. During the procedure the patient is mildly sedated but otherwise alert and not intubated. We do not use any more trans-esophageal echo or extracorporeal percutaneous femoro-femoral bypass or any other form of assist device, as requested per protocol for implantation of the first and second generation devices.
However, even in cases with moderate regurgitation, there are options available for further ‘tuning’ of the valve. In case of underexpansion, a further post dilatation of the already implanted valve can be carried out safely and efficiently, reducing effectively the regurgitation. Pulling of the CoreValve prosthesis in case of deep implantation is also feasible, by means of snare pulling. Noteworthy is the fact that all these manipulations can be carried out interventionally, avoiding the need of a cardiothoracic surgeon and the associated risks of turning the procedure into an open heart surgery.