Richard A Hopkins

Hemi Pulmonary Artery Homograft

The median sternotomy is performed in the usual way. Cannulation is accomplished as high on the ascending aorta as possible or as femoral artery cannulation.We use a single atrial return cannula but bicaval cannulation is preferred by some authorities or by us when other reconstructive procedures are needed in the patient.1-3 Left ventricular venting is accomplished via the right superior pulmonary vein. Mild total body hypothermia is used with car-dioplegic arrest supplemented by topic slush...

Tubular Hypoplasia of the Transverse Aortic Arch with or without Coarctation

Hypoplastic Transverse Aortic Arch

When coarctation is associated with a diffusely hypoplastic transverse aortic arch, coarctation repair alone may not relieve the aortic obstruction because of residual obstruction across the hypoplastic transverse arch. These patients may have an associated ventricular septal Figure 61.12. The upper one-half of the anastomosis, both anteriorly and posteriorly, is made with a running suture. Figure 61.12. The upper one-half of the anastomosis, both anteriorly and posteriorly, is made with a...

Damus KayeStanzel Anastomosis with or without Aortic Arch Augmentation

Damus Kaye Patch Revision

Those patients with subaortic obstruction and who are destined to a single ventricle repair (Fontan) and who have a normal pulmonary valve, can frequently undergo a Damus Kaye Stanzel anastomosis.7'8 This involves association of the divided proximal main pulmonary artery with the aortic arch so that the unobstructed outflow tract to the pulmonary valve an be utilized for systemic outflow to the aorta (Figure 61.20). Depending upon the anatomy and relationship of the great vessels and whether...

Anatomy and Classification

In 1949, Collett and Edwards1 proposed a classification system based on the arrangement of the origins of the pulmonary arteries from the truncal artery (Figure 56.1). The classification proposed by Van Praagh and Van Praagh2 also includes cases with a single pulmonary artery and various degrees of development of the ascending aorta and ductus arteriosus. In the Collett and Edwards Type I truncus, the pulmonary arteries arise from a common pulmonary trunk that originates from the truncus. In...

Techniques to Minimize Aortic Insufficiency

Modification Manouguian Techniques

Taking these findings into account, several technical aspects may be important in minimizing the development of aortic insufficiency after the Ross procedure. The experience of Ross would suggest that implanting the pulmonary valve inside the aortic root might have significant merit. Certainly, the potential for dilatation of the aortic root would be minimized if the pulmonary valve is sewn freehand in a sub-coronary position or placed inside the aortic root as a cylinder (inclusion technique)....

ECM Scaffolds

The development of an ECM scaffold has been occurring in parallel with the research activities focusing of biodegradable polymers. As discussed above, the limitations imposed by synthetic biodegradable materials such as the polymer degradation rate and biomaterials properties, may be circumvented by the selection of a tissue-derived biomaterial capable of accommodating the biomechanical requirements of a HV. Decellularized (also referred to as acellular or devitalized) aortic and pulmonary...

Proximal Suture Line

Maintain Aortic Root Replantation

After preparation of the allograft and resection of the native valve, three sutures of 4-0 monofilament polypropylene on a taper-point half-circle needle are placed as simple sutures, relating the middle of each recipient sinus to the donor coronary ostia (Figure 32.3). They are placed as simple sutures beginning with the base of the left sinus of the allograft lined up to a position directly underneath the left coronary of the recipient (Figure 32.4). Similarly, a simple suture is placed...

Safety and Toxicity

One of the principal safety concerns associated with the use of aprotinin is the potential for thrombotic complications including early saphenous vein closure and perioperative MI and stroke. Cosgrove et al.4 reported a trend toward an increased incidence of MI in apro-tinin treated redo-CABG patients. Although not statistically significant, the incidence of Q-wave infarction was 17.5 in a high-dose aprotinin group versus 8.9 in a control group. In addition, autopsies of seven patients who died...

Mayo Clinic Series

Orszulak The use of cadaveric aortic valve homografts for the replacement of diseased aortic valves began at the Mayo Clinic in 1965. The impetus for initiating this program was concern regarding the available prosthetic valves, especially the hemodynamic characteristics and the incidence of thromboembolism, and the favorable early results achieved by Donald Ross1 and Brian Barrett-Boyes2 in the use of aortic valve homograft in the subcoronary position beginning...

Pulmonary Artery Bifurcation Allograft

When the pulmonary arteries are nonconfluent, choices exist for reconstruction. First, the pulmonary artery bifurcation can be reconstructed entirely with a pulmonary bifurcation allograft with separate end-to-end anastomoses right and left, as reported by McGrath and colleagues (Figure 53.22), or sewn to an aortic allo-graft in a manner analogous to the technique just described when the distance is great (Figure 53.23). Second, the absent posterior wall of native pulmonary arterial confluence...

The role of Homograft Valves in the Treatment of Endocarditis

Homograft Aortic Valve

The value of surgical intervention in patients with NVE who develop heart failure, uncontrolled infection and aortic root abscess formation has been previously demonstrated.18 Similarly, surgical therapy for some patients with PVE18,19 has improved the high mortality associated with this condition. Patients with PVE and heart failure, uncontrolled sepsis, prosthesis dehiscence, prosthesis obstruction and fungal etiology are the ones most likely to benefit from valve replacement. One of the...

University of Alabama at Birmingham Series

Homograft Aortic Valve Replacement

Kirklin Homograft valves have proved a useful replacement device in the management of aortic valve and aortic root pathology. Since the first insertion by Ross,1 in 1962, a number of different methods of homograft valve collection, sterilization, storage and insertion have been used. Consequently, this has made comparison of results between the centers that have achieved considerable experience with this valve difficult. The purpose of this section is to present...

Bicuspid Aortic Valve with 180 Coronary Ostia

Aortic Valve Coronary Ostium

In a situation where the coronary ostia are at 180 angles from each other in the native aortic root, simple orthotopic placement of a trileaflet valve would be defeated. Once again, if the allograft aortic valve is clearly the optimal choice for the patient, it can be managed with enlargement of the non-coronary sinus region of the native aortic root with or without an annuloplasty. Most often, an annuloplasty is also required that rotates the native coronary Figure 34.12. Large native left...

Asymmetric Placement of Coronary Ostia Within Native Sinuses Mini Rotation

Right Coronary Ostium

A common geometry involves rotational displacement of the right coronary orifice to the right within its sinus such that the right and left coronary ostia begin to approach 180 Figure 34.10 . Occasionally, asymmetry of the allograft sinuses allows management by rotating sinuses e.g. allograft left to recipient right . Usually placement of an allograft inside this geometry requires a slight rotation, placing the left coronary ostia closer to the pillar between the left and non-coronary sinuses...

Aortic and Pulmonary Valves General Morphologic Features

Heart Valve Aortic Histology

Aortic and pulmonary valves are referred to collectively as semilunar valves. The normal aortic valve is non-obstructive when open, competent when closed, non-thrombogenic, non-injurious to blood cells, durable, resistant to infection and, capable of continuously remodeling its extracellular matrix and repairing itself when injured. The dilated pockets of aortic root behind the valve cusps bulge with each systolic ejection of blood and are called sinuses of Valsalva.1 Normally, the three aortic...

Nicks Technique

Nicks Aortic Root Enlargement

The method of Nicks and coworkers can be adapted for use with allografts.4 It is an incision similar to that originally described by Barratt- Boyes.5 The incision across the annulus is made to the right of the commissure between the left and noncoronary sinuses of the native aortic root and extended into the anterior leaflet of the mitral valve Figure 33.6 . It is posterior to the bundle of His. If only a small amount of Figure 33.6. Enlargement of the annulus by extension of the aortotomy...

Preclinical Studies

Apoptotic Bodies

Preclinical animal studies involving allograft heart valves have been conducted predominantly in non-orthotopic models in which an allograft valved-conduit also referred to as an aortic root has been implanted in the systemic circulation thus avoiding the need for car-diopulmonary bypass.1'2 Reconstruction of the right ventricular outflow tract has been accomplished in lambs using cryopreserved and antibiotic-disinfected aortic valve allografts.3 To the best of our knowledge, orthotopic aortic...

Coronary Arterial Anatomy in Normal Hearts

Left Bundle His Branch Anatomy

Critical for safe excision of the autograft is a knowledge of the anatomy of the left coronary artery. The main stem of the left coronary has been reported to vary in length from 2-20 mm.5 In the hearts examined, its length was from 1 to 8 mm. The first branch of the left anterior descending may be a infundibular branch, completing the ring of Vieussens, but the descending artery gives off from 3 to 6 perforating arteries.6 There is some discussion over whether all are similar in size, or...

Homograft Valve Insertion for Endocarditis

Aortic Homograft Figures

The general principles of the surgical management of endocarditis include a timely valve surgery in the setting of appropriate bactericidal antibiotics, b debridement of all infected tissue including abscess cavities and the infected fibrous skeleton of the heart, c removal of all prosthetic material in PVE, d reconstruction including valve replacement, annular reconstruction and closure of any holes between chambers. Abscess cavities are not specifically closed unless required for the...

Surgical Techniques

Left Ventricule Suture

The heart is cannulated for cardiopulmonary bypass utilizing ascending aortic cannulation relatively high near the innominate artery and dual vena caval cannulas. Prior to aortic cross-clamping, the aorta and pulmonary artery are fully mobilized. There are usually adhesions from previous operations. After induction of cardioplegic arrest, a vertical aortotomy is performed, begun anteriorly and directed slightly to the left of the right coronary ostia Figure 36.1 . The aortotomy is retracted...

Surgical Technique

Patch Enlargement Left Outflow Tract

Moderate to deep hypothermia is used in all cases with cannulation for bypass being achieved with an arterial cannula placed distally at the level of the innominate artery or beyond to permit wide mobilization of the ascending aorta. A single venous cannula in the atrial appendage is usually adequate. In most cases the procedure can be performed without a period of circulatory arrest other than for closure of the interatrial communication. Once on bypass, access to the left ventricular outflow...

Modified Root Replacement Concept Influence of Implant Technique on Allograft Durability

Needle Attachment Sutures

Indications for the use of allografts for aortic valve replacement should be built upon an appreciation that this is non-viable collagen tissue, which will be subjected to a slow, variable but relentless immunological response, destined for eventual deterioration. Allograft durability and the performance characteristics which relate to durability depend upon several factors. These include donor age, procurement and preservation techniques, as well as immunogenicity. A primary issue, is that the...

Lloyd Wolfinbarger Jr Kelvin GM Brockbank and Richard A Hopkins

The intention of this chapter is to deal with the issues associated with the cryopreservation of heart valves and to review some of the approaches taken to resolve these issues. Cryo-preservation protocols have been developed empirically, based upon knowledge gained from the cryobiology of single-cell suspensions, and these protocols have consistently provided valves that perform adequately for extended periods of time.1 It now becomes important to find out why cryopreserved allogeneic valves...

Reduction Aortoplasty

Aortoplasty

Barratt-Boyes5 and Ross and associates6 have emphasized the role of aortic root reduction, or tailoring, to reduce the size of the aortic root. One of the major reasons cited for failure in Barratt-Boyes' 1987 review was dilated aortic root. His group advised against placement of an allograft in a root larger than 30 mm in diameter, although they did recommend placement if the aortic root could be tailored to a diameter Figure 34.1. Effect of splaying and convergence of ation of the allograft...

Richard A Hopkins and Gary K Lofland

Subaortic Stenosis And Single Ventricle

Homograft tissue can be used in creative ways to reconstruct systemic outflow by dedicating the pulmonary valve to the systemic ventricle, using nonvalved homograft tissue to augment the neo-LVOT outflow, and re-establishing with a second homograft, pulmonary ventricle to pulmonary continuity, or in the case of single ventricle, performing a variation on the Norwood operation. Double Outlet Right Ventricle with Transposition of the Great Arteries and Hypoplastic Aorta with Either Interrupted...

Coronary Ostia Arising High in the Sinuses

High Positioned Left Coronary Ostium

In the case of the coronary ostia arising high in the sinuses, the problem for the surgeons is simplified. Resection of the allograft coronary sinus can be minimized, and the proximal suture line placed conveniently at the bottom of the sinus at the level of the native leaflet attachment Figure 34.16 . The distal suture line is comfortably created around the coronary orifice. Note that the proximal suture line does not follow the semilunar cusp attachment superiorly but, rather, crosses the...

Cellular Components

Heart Valve Ventricularis

Four major types of cells are present in cardiac valves 1 endothelial cells 2 interstitial connective cells 3 mononuclear cells derived from the blood, and 4 interstitial dendritic cells. The endothelial cells form a continuous monolayer that completely lines the surfaces of the valves and is contiguous with the endothelial cell layer of adjacent regions of the endocardium and or great vessels. These cells are flattened, have single, centrally located nuclei, contain actin-like and intermediate...

The Use of Homograft Valves Historical Perspective

In 1956 Gordon Murray reported the use of fresh aortic valve homografts transplanted into the descending thoracic aorta for amelioration of the consequences of native aortic valve insufficiency. His initial operations preceded by 5 years the availability of the Starr-Edwards mechanical aortic valve prosthesis.1-7 Although this operation was only partially successful hemodynamically, the homograft valves had remarkable durability and performance. Four patients cited by Heimbecker had no...

Evaluation of Pulmonary Autograft Function

Following transplantation of the pulmonary autograft, TEE evaluation of the autograft function is critical to assess immediate surgical adequacy and predict the long-term results. In their retrospective series of 145 Ross operations Stelzer et al.1 noted the consistent absence of any significant pressure gradient across the autograft on early and late follow-up echocar-diographic examination. In this series and others, a tiny central jet of aortic regurgitation AR is commonly seen. Mild...

Anatomy of the Right Ventricular Outflow Tract

Aortic Valve Annulus Size

Before describing variations in coronary arterial anatomy, it is imperative to have a clear understanding of the anatomy of the pulmonary valve, specifically of the components of the pulmonary infundibulum Figure 40.1 . Excellent work in this area was published many years ago,2'3 and will be amplified here. The pulmonary valve is, in most cases, a trileaflet valve supported by a muscular infundibulum. The infundibulum has two com ponents, a free-standing component existing in a plane superior...

Donor Suitability

Permission for heart donation is usually obtained in writing or via a taped, documented telephone conversation with the donor's legal next of kin, even if a potential donor carries an organ donor card. Alternatively, a self-signed donor document can be accepted as long as it is in accordance with the Uniform Anatomical Gift Act and applicable state and local regulations. Once permission is obtained, the donor must be adequately screened to minimize any potential transfer of an infectious...

Surgical Technique for Standard Aortic Root Replacement

As Ross originally devised, we use an interrupted proximal suture line technique.45 The aortic root is excised and the native coronary ostia left on large buttons of aortic tissue Figures 35.1, 35.2, and 35.3 . An additional septal myomectomy is performed if necessary Figure 35.4 . The allograft is then oriented in the orthotopic position, with the left coronary ostia comfortably positioned toward the button of the native left coronary ostia. The proximal suture line is constructed of a series...

Sterilization and Disinfection

In order to provide a disinfected allograft for transplantation, identification and elimination of any potential contaminants are required. AATB Standards dictate that processing shall include an antibiotic disinfection period followed by rinsing, packaging, and cryopreserva- tion, and that disinfection of cardiovascular tissue shall be accomplished via a validated, time specific antibiotic incubation. Disinfection involving incubation of the allograft in low-concentration, broad-spectrum...

Thawing and Dilution Prior to Surgical Preparation of the Allograft

Preparing the frozen allograft for transplantation involves thawing the tissue at a specific rate, diluting the cryoprotective agents, and restoring the cryopreserved tissue to osmotic isotonicity. Careful handling of the allograft and strict adherence to protocols are imperative. To maximize cellular viability and matrix structure, heart valve leaflet manipulation should be kept to a minimum. After thawing and dilution, the recovering heart valve should be kept moist and bathed in a...

Heart Valve Evaluation and Examination

Conduit Length Cardio Vascular

The AATB Standards mandate a standardized evaluation and classification system for allo-graft heart valves. This evaluation should include sizing and a qualitative graft assessment. A system must be in place to notify the implanting surgeon of any graft's condition if requested prior to final dispensing. Sizing the allograft is a vital aspect of the processing procedures consistency and accuracy are of the utmost importance. Incorrect sizing of the allograft aortic root diameter could require...

Surgical Technique for Scalloped Subcoronary Insertion

Surgical Sutures Technique

The scalloping of the valve is either accomplished by the manufacturer or can be performed by the surgeon prior to or after the proximal suture line has been accomplished. Aortotomy is performed in one of two ways depending upon whether the ascending aorta at the level of the sinus ridge is of the diameter desired at the conclusion of the repair or is enlarged. A transverse aortotomy is performed above the level of the sinus ridge if the sinus ridge anatomy appears appropriate where as a Lazy S...

Incidence of Aortic Insufficiency After the Ross Procedure

The incidence of aortic insufficiency after the Ross procedure is not well known, primarily due to the limited amount of published experience in this regard. Of course, the initial expe rience with this technique was that of Mr. Ross himself. Long-term follow-up of Ross' experience was reported in 1991 and included 339 patients beginning with his first patient in 1967.1 The mean follow-up was 11.8 years and maximum follow up was 24 years. In that entire group of patients, the number of patients...

Extracellular Matrix

Extracellular Matrix Stain

Cardiac valves are primarily composed of extracellular matrix components of connective Figure 22.5. Transmission electron micrograph demonstrating the loss of collagen crimp, as shown by collagen fibril elongation or straightening. High pressure-fixed porcine aortic valve. x 2,900. Figure 22.5. Transmission electron micrograph demonstrating the loss of collagen crimp, as shown by collagen fibril elongation or straightening. High pressure-fixed porcine aortic valve. x 2,900. Figure 22.6....

Aortic Root Replacement with Stentless Porcine Heterografts

Braun Patch Aortic Valve

For complex aortic root anatomy or for infected aortic roots, it is sometimes preferable to completely replace the entire aortic root rather than using a miniroot or subcoronary scallop technique. In this case, the operation is very similar to that described for the aortic root replacement with a homograft. Sizing is accomplished utilizing either Hegar dilators or sizers provided by the companies. Only the intact aortic root heterograft prosthe ses are suitable for this technique. The size of...

Robert H Messier Jr Diane Hoffman Kim and Richard A Hopkins

Cardiac valve leaflet interstitial cells LIC provide the essential synthetic means of continuous matrix production and remodeling within the valve and possess contractile functions that likely contribute to the valve's enormous capacity for endurance. In light of their importance, the present chapter focuses on these cells' capacity to maintain a viable, functional population, both in culture and after typical post-harvest processing. Two studies have looked at the responses of LIC to isolation...

Cooling Protocol

An average adult heart valve to be cryopre-served is typically 6 cm in length from the annulus to the distal aspect of the aortic conduit. The valves are sized based on internal diameter and the average thickness of the aortic wall is approximately 1.6 mm. Valves are usually frozen in a total volume of 100 ml and the valve typically constitute 7-15 of the total volume to be frozen. Several considerations must be taken into account in the cryogenic preservation of biological tissues. The rate of...

David C McGiffin and James K Kirklin

James Kirklin

Infective endocarditis, both native and prosthetic, is ultimately a fatal illness without therapy, reflecting the inability of innate defenses to importantly influence the course of the disease. Following the diagnosis, the therapy of this illness depends on identification of the organism, administration of bactericidal antibiotics and the use of timely cardiac surgical intervention in patients with complications such as heart failure from valvular destruction, annular abscess formation,...

Heart Procurement

The time period from cessation of heartbeat until cardiac procurement as the warm ischemic time and the time interval from placement of tissue in cold transport solution to the beginning of disinfection as the cold ischemic time. The AATB Standards permit cardiovascular tissue recovery to be established by each individual bank however the following upper time limits for completion of retrieval and processing of cardiovascular tissues may not be exceeded 1. Warm ischemic time shall not exceed 24...

Manouguian Technique

Nicks Enlargement Annulus Technique

The method described by Manouguian and Seybold-Epting for prosthetic valve placement and enlargement utilizing a pericardial patch sutured into the anterior leaflet of the native mitral valve can be adapted to a technique applicable to freehand allograft insertion.3 The aortotomy is extended somewhat more posteriorly than usual through the region of the native commissure above the midpoint of the anterior leaflet of the mitral valve Figure 33.1 . The depth of the incision into the left atrium...

MG Hazekamp DR Koolbergen J Braun JA Bruin CJ Cornelisse YA Goffin and JA Huysmans

Efforts in preservation of allograft heart valves aim at remaining cellular viability. Viability in this respect always means fibroblast viability as endothelial cells are almost completely lost in the sequence of dissection, sterilization, cryopreservation, thawing and implantation.1'2 Cryopreservation is now considered to be the method of choice of allograft heart valve preservation and banking. Cellular viability after cryopreservation has been well documented.3-5 The length of donor...

Allograft Valves and Other Replacement Heart Valves

Jude Mechanical Aortic Valve

The first clinical implantation of a mechanical replacement heart valve was performed in 1958 using a ball-in-cage valve inserted in the descending thoracic aorta.6 The first orthotopic valve replacements were accomplished in 1960 aortic position 7 and 1961 mitral position .8 Mechanical heart valve designs continued to evolve, with the current prosthetic designs consisting of ball-in-cage, tilting disk and bileaflet valves. The occurrence of thromboembolic events and of sudden, life-threatening...