[[400 Technical Outline of Aortic Valve Replacement]] # Aortotomy Closure after Aortic Valve Replacement - Consider turning the LV vent off as you want to minimize the opportunity to entrain air into the heart - Suture line options - Single suture line, continuous baseball stitch - Absolutely an option, as it is for an aorta-to-aorta anastomosis - Small aortas, particularly those that have been transected for optimal exposure are often best closed this way - If the tissue is friable, or the margin relative to the RCA is narrow, it is easy to add a layer of teflon or pericardial pledget to the suture line to reinforce it - Double suture line, both continuous baseball stitches - I've seen it done by talented people, but I really don't see the advantage of it - If two layers are better than one, why not just make the first layer take twice as many bites? - Double suture line, first running horizontal mattress, second running baseball stitch, otherwise known as the Cooley closure - I believe this to be the superior closure technique - The first layer approximates tissue on either side of the aortotomy, matching it up while contributing to the overall hemostasis - When completed, it helps stop the entrainment of air into the LV - In a large diameter aorta, where you have exaggerated the aortotomy and aligned it more with the direction of the aorta, the first layer can "reef" in the aorta. You may even take the option of trimming some of the "reef" above the first suture line before beginning the second. - It sets a marker for the depth of the second layer, avoiding misadventures with the ostium of the Right Coronary Artery - The second layer provides the augmented hemostasis - Despite the "reefing" effect, when you reoperate on these closures (hopefully many years later), the aorta looks normal at the suture line, tubular and indistinguishable from any other segment of the aorta apart from the prolene. - In the course of closure over a tissue prosthetic, you may run into the situation where the posts of the valve are making contact with the aortic walls. - A little contact is acceptable. The blood pressure distending the aorta when the heart is once again in motion will take care of things - If the posts are truly being impinged upon, use a dacron patch or pericardial patch to augment the closure in a manner analogous to my version of the Manougian. - A single suture line along the entire margin of the patch, the full length of the aortotomy, proximal and distal lips, is quite hemostatic. - These aortas are often short of real estate, and the patch can be a good place from which to originate a vein graft for a proximal. - You should have gained an appreciation for the position of the RCA ostium by this point. If not, visualize it, and consider putting in a right angle clamp or antegrade cardioplegia catheter to confirm its patency and location - Put a blue towel underneath your aortic cross clamp - This will elevate the clamp, approximating the distal lip of the aortotomy towards the proximal lip - This will diminish the chances of the mattress layer creating micro tears in the aorta because of tension - Place a pledgeted 4-0 prolene mattress stitch at the Pulmonary end of the aortotomy - "Start where the incision isn't", that is to say, at least one, possibly both bites of the first stitch should be beyond the start of the incision - Both bites are forehand, from the surgeon's side - One arm passes outside-in, aorta proximal lip - Then inside-out, aorta distal lip - Then through a free pledget - Second arm, same set of motions, the width allowed by the pledget, along the incision toward the surgeon - Then through the same free pledget - Leave both needles on, tie down the 4-0 prolene with four or five throws - The needles have an annoying tendency to act as grappling hooks and screw up the knot - This can be avoided if you don't tighten the throw until you are certain the needles have passed through the throw - Avoid "pre knots", don't knot the suture, and be relieved with "pseudo-knots" - Put one arm on rubber-shod crile clamp - Mattress towards yourself with the other arm - Between the cramped quarters of the angle, the position of the L-R post of a tissue valve, the first mattress is often done best in two bites - Advance about 5 or so millimeters - You go outside-in distal lip, forehand towards yourself - Pick a spot corresponding to the opposite position on the proximal lip - Inside-out proximal lip, backhand - Advance about 5 or so millimeters - Next bite can now be taken in one - Forehand outside-in proximal lip, pick a spot opposite this on the distal lip, forehand inside out - The assistant maintains enough tension to approximate the lips without tearing small holes in the aortic wall, and distracts the RCA/RVOT margin tissue away from the proximal lip when you are passing the needle through it. The assistant should also try to align the adventitia so the bites go through all layers appropriately. They should also be "following" to keep excess suture out of your way while allowing you freedom with the remaining length of suture - Next bite can often be taken in one - Advance about 5 or so millimeters - Backhand outside-in distal lip, opposite position proximal lip, backhand inside out - Repeat steps until you are in a position directly anterior on the aortotomy closure, coming out the distal lip - Even though you will want to keep going with this arm, if you do, you will interfere with your view of the other half of the closure. - Tag this end with a rubber-shod crile - Weigh down this arm with a tubing clamp through the finger holes of the rubber-shod crile to maintain tension - Place a pledgeted 4-0 prolene mattress stitch at the SVC end of the aortotomy - The steps are very much the same except that nearly all bites can be taken in one - When you reach the middle of the aorta, try to end on the same distal lip next to or with a little overlap with the suture from the other side of the aorta - Cut off these needles - Definitely turn off the LV vent - Ask for perfusion to fill in the RV a little - Gently squeeze the heart with your right hand to move some of the blood through into the LV - While distracting the two lips at the middle of the closure, ask the anesthesiologist to give a series of three or four deep bag ventilations - This will eject blood from the pulmonary veins, forcing out as much of the air that has risen into them by excessive action of the LV vent as possible - When the blood that is being forced out of the aorta by these motions has no large bubbles of air visible, ask the anesthesiologist to "Bag and Hold" - Instruct perfusion to empty out the RV, LV vent stays off - Tie down the prolene - Tell anesthesia to release the lungs - Root vent on low, only enough to decompress the aorta, not enough to suck air through the mattress suture line. - Begin the second layer of the Cooley closure - You can choose either side to begin with - The first bite of the second arm goes forehand back through both of the anchoring pledgets on the same side - In between bites, the assistant maintains good tension - I find the taut prolene shows me where to put the next bite - Stop when you reach the most anterior part of the aorta, and begin with the other end of the aortotomy aftering anchoring the prolene you left with a rubber-shod/tubing clamp combination - Cut the needles off - Tie down the prolene. - If you wish it, the suture line can be tested with cardioplegia, or warm blood as circumstances dictate, delivered with the cross-clamp in place, or the cross clamp can be removed. - Unless something is really quite wrong, the LV vent should still not be necessary - Inspect the suture line, put fix-its as necessary - "The angle of sorrow", the pulmonary end of the aortotomy can be difficult to repair in some situations, which is why the steps described above were designed