A 59-year-old female patient with asymptomatic severe AR was referred to our institution for surgical treatment. She was being followed up at an outpatient clinic for QAV and moderate AR for 7 years. AVR was indicated for the progressively worsening AR and left ventricular function.
On admission, the patient’s blood pressure was 122/62 mmHg, and heart rate was 102 bpm with an irregular rhythm. Chest radiography showed a cardiothoracic ratio of 56%. Electrocardiography (ECG) revealed a heart rate of 100 bpm with atrial fibrillation. Transthoracic echocardiography revealed a QAV with a severe central AR jet due to incomplete coaptation. The left ventricular ejection fraction was 50%, without local asynergy. The left ventricular end-systolic and end-diastolic diameters were 46 mm and 62 mm, respectively, and the diameter of the aortic valve annulus was 23 mm. Coronary angiography revealed no significant coronary artery stenosis or anomalies. ECG-gated enhanced computed tomography was not performed, and no coronary ostium anomalies were detected preoperatively.
The patient underwent median sternotomy. The aortic valve had four cusps of almost equal size (Hurwitz and Roberts type A , Fig. 1). Macroscopically, partial calcification and thickening of the cusps were observed. The left coronary ostium was located in the middle of the left aortic sinus, whereas the right coronary ostium was located near the commissure between the right coronary cusp and one of the two non-coronary cusps. After excision of all cusps, the annular stitches were placed in a non-everting mattress fashion with pledgets on the ventricular side, and three stitches near the right coronary ostium were transitioned to the subannular ventricular myocardium to maintain the distance from the ostium (Fig. 2). We decided to use a biologic prosthesis, according to the patients’ desire. Although a 25-mm prosthetic sizer could pass through the annulus, we selected a 23-mm Inspiris Resillia biologic prosthesis (Edwards Lifesciences, Irvine, California, United States of America), because an oversized prosthetic valve could potentially compress the right coronary ostium. In addition to AVR, pulmonary vein isolation using AtriCure (AtriCure, Mason, OH, USA) and left atrial appendage closure using AtriClip (AtriCure) was performed for atrial fibrillation.
The patient tolerated the procedure adequately, and postoperative echocardiography revealed normal prosthetic valve function without paravalvular leakage. Except for recurrent atrial fibrillation, the postoperative course was uneventful. The patient was discharged on postoperative day 17.