UDC 616.126 -002 407.-08-097
POSTERIOR AORTOPLASTY FOR ISOLATED AORTIC VALVE REPLACEMENT COMPLICATED BY NARROW AORTA`S OSTIUM
Popov V. V., Antoshenko A.A., Beshlyaga V.M., Trembovetskaya O.M., 
Zaharova V.P., Rybakova O. V., Dzahoeva L. S., Atamanyuk M. Ju., Tihonenko L.I., Hyznyak K. A., Horoshkovataya O. V., Volkova N.I.
National Amosov’s Institute of Cardiovascular surgery NAMS of Ukraine (Kyiv)
                                               
103 patients with isolated aortic valve disease with narrow aorta’s ostium operated in Institute from 1 May 2009 until 01 Jan 2016 are included in analyzed group. Among 103 patients on the hospital stage 7 died (hospital mortality - 6,9%). There were no remarks to surgical technic in any case. Dynamic of echo-data on hospital stage: gradient of systolic pressure of left ventricle (LV) before operation 115,1+11,5 mm.Hg., on aortic prosthesis at discharge 25,9±4,1 mm.Hg. Reconstruction of root and ascending aorta after proposed method in a case of hypoplasia of aorta and aortic valve replacement (AVR) is highly effective intervention. Aim of this research is to study possibilities of new approach to reconstruction of root and ascending aorta in AVR. 
Key words:  narrow aorta`s ostium, dilatation of root and ascending aorta, aortic valve replacement, cardiopulmonary bypass
MATERIAL AND METHODS
103 patients with isolated aortic valve disease with narrow aorta’s ostium underwent surgical treatment in department of acquired heart diseases in Institute from 1 May 2009 till 01 Jan 2016 are included in analyzed group. There were 69 males(66,9%) and 34 females (33,1%). Age of patients varied from 23 to 72 years (average 59,7+5,7 yy). 21 (20,4%) patients belonged to III functional class of heart failure after NYHA classification, 82 (79,6% ) – to IV class. Main etiological factor of disease was rheumatism in its combination with lipoidosis. Aortic valve calcinosis “3+” was marked in 98 (95,3%) patients. In 2 cases plasty of aorta’s root was fulfilled after previous aortic valve replacement and in 2 cases after open aortic valvulothomy.
Aortic valve replacement in combination with reconstruction of root and ascending aorta was fulfilled in all cases by original methodic (Popov V. V.). The method essence consists in the following. After beginning of cardio-pulmonary bypass and clamping, ascending aorta is dissected by slanting cut with continuation on a joint to coronary and non-coronary cusp with followed dissection of fibrous annulus on depth to 5 mm. After that second cutting of aorta with continuation to fibrous annulus with displacement towards the right fibrous triangle. 
Aorta between joint of coronary and non-coronary cusps is dissected. Cusps of aortic valve are dissected. Aortic prosthesis with fixation of 18-20 П-shaped sutures in ventricle-aortic position, including 7-8 in projection of non-coronary cusp are implanted with prolen 2-0 through synthetic patch “Vascutek” 4х3 cm. Dissection of ascending aorta was fulfilled by patch, fixated by prolen 4-0 and has been strengthened along the edges by teflon. Bileaflet prosthesis (Carbomedics,Saint Jude Medical,On-X, биопротез) in sizes: 21 (9 patients), 23 (86 patients), 25 (7 patients) 27 (1 patient). Concomitant aortic stenosis was dissected in 3 cases. 
All operations were performed in conditions of cardio-pulmonary bypass and moderate hypothermia (32-34°C). Myocardial protection was fulfilled in conditions of retrograde pharmacological cardioplegia by solution of Custadiol in combination with external cooling of the heart. 
Time of cross-clamping on the initial stage of working out a procedure was 112,4+5,1 minute, and during 2011-2012 yy  77,5+6,1 minute. Blood-loss was in 89 (84,2%) operated within 450 ml. In 11 (10,6%) patients during  the whole period of operation and further during postoperative period donor blood and its components were not used. 
RESULTS AND DISCUSSION
Among 103 patients on the hospital stage (30 days after operation) 7 died (hospital mortality 6,9%). Causes of death were: cancer intoxication (1), coagulopathy (1), thromboembolism of lung artery (1), lung bleeding (1), MOF (3). There were no remarks to the surgical correction. Inotropic support (dobutamine) in early postoperative period was 3-4 microgr/min/kg during first 48 hours. Stay on artificial ventilation in average 9,5+2,4 hours. Stay in intensive care unit within 83,5+3,45 hours.  Patients were discharged in average on 13-14 day after operation without clinically significant complications. Dynamic of echo data on hospital stage: gradient of systolic pressure on outflow tract of left ventricle before operation 115,1+11,5 mm. Hg., on the aortic prosthesis at discharge 25,9±4,1 mm. Hg., end-systolic index (ml/m²) – 57,3+7,4 (before operation) and 49,3+5,5 (after operation), ejection fraction of left ventricle 0,47+0,03 (before operation) and 0,55+0,05 (after operation). 

CONCLUSION
In a case of concomitant aortic valve disease hypoplasia of aorta’s ostium is serious problem and is associated with high hospital mortality (1-4). Associated with it complications on a hospital stage are caused by high frequency of acute heart and vessel insufficiency, which with small size of implanted prosthesis leads to high transprosthesis gradient and progressive heart failure (1-4). Both on the hospital stage and in the remote period absence of regression of LV’s hypertrophy causes conditions for dangerous arrhythmia. Quality of life, survival, stability of goof results in this group is not high. 
At the same time reconstructive procedures on a root of aorta (posterior aortoplasty) with the aim of its widening and optimization of size of prosthesis during aortic valve replacement is associated with high risk of blood-loss, in spite of allows radically improve morphometric and quality of remote period (1-4). Reconstruction of root of ascending aorta in aortic valve replacement is highly effective procedure, providing good direct result. Method excludes possibility of bleeding from the correction zone and developing of clinically significant heart and vessel insufficiency. It allows improve significantly hemodynamic, contractility, morphometric of left chambers by implantation of aortic prosthesis in adequate size and excluding mismatch in postoperative period. 
It is important to research middle-term results of proposed method. 

References
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