State of the art in reconstruction of the ascending aorta with or without valve reconstruction
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1 State of the art in reconstruction of the ascending aorta with or without valve reconstruction PD Dr Diana Aicher Universitätskliniken des Saarlandes Homburg/Germany ESBV Straßbourg, May
2 Background Atherosclerosis, connective tissue disorders, and congenital aortic valve abnormalities (bicuspid or unicuspid anatomy) cause aneurysmatic dilatation of the ascending aorta. Operative replacement of the dilated aorta is necessary to avoid complications like dissection or rupture.
3 Background If dilatation includes the aortic root, combined replacement of the valve and ascending aorta is necessary. Standard technique is the Bentall procedure. Alternative techniques are valve-preserving techniques.
4 Valve sparing aortic root replacement Remodeling Sarsam/Yacoub 1993 JTCVS 105;3: Reimplantation David 1992 JTCVS 103;4:
5 Replacement of the ascending aorta with preservation of the valve Abscence of calcification/valve stenosis Root dilatation (Sinus > 42-45mm) ± regurgitation Sinutubular junction Sinus Aortoventricular junction
6 Remodeling of a bicuspid aortic valve Operative Steps: 1. Root assessment: TEE (long axis): AV diameter sinus diameter ST diameter
7 Remodeling of a bicuspid aortic valve Operative Steps: 2. Exposure: standard cannulation longitudinal incision transsection of aorta (5mm above commissures) stay sutures above commissures
8 Remodeling of a bicuspid aortic valve Operative Steps: 3. Mobilization of the Root: geometric height AV diameter
9 Remodeling a of bicuspid aortic valve Operative Steps: 4. Tailoring of the graft: symmetric tonques Incisions for commissures 20% less than anticipated
10 Remodeling of a bicuspid aortic valve Operative Steps: 5. Suture Graft to Root: from the center of a sinus to the commissures fused cusp (left/right) à non-coronary sinus
11 Remodeling of a bicuspid aortic valve Operative Steps: 6. Assess cusp configuration: effective height
12 Remodeling of a bicuspid aortic valve Operative Steps: 7. Reconstruction of AV (AVJ > 25mm)
13 Remodeling of a bicuspid aortic valve Operative Steps: 8. Final check: TEE: Aortic regurgitation (central, eccentric, degree) configuration of the valve effective height
14 Valve preserving surgery (10/1995-3/2009) Remodeling Reimplantation p (N=401) (N=29) Age (years) 58 ± ± 16 Sex (m/f) 300/101 19/8 Tricuspid AV BAV/UAV 124/6 2/- Diagnosis: Aneurysm AADA 59 7 CADA 6 - Marfan Myocardial Ischemia (min) 82 ± ± Hospital mortality total 13/401 (3.2 %) 0/ elective 9/342 (2.6%) 0/ emergency 4/59 (6.8%) 0/ Kunihara et al. JTCVS 2012 Jun;143(6):
15 Aortic Root Repair (Homburg) Survival Aortic Root Replacement (Composite) 84% 68% 47% 60 % Follow-up (months) Etz et al. JTCVS 2007
16 Freedom from reoperation Kunihara et al. JTCVS 2012 Jun;143(6):
17 Kunihara et al. JTCVS 2012 Jun;143(6):
18
19 Conclusions Early mortality is comparable after the Bentall procedure and valve preserving root replacement Valve-preserving root replacement leads to excellent long-term valve durability, if a good aortic valve configuration can be achieved Ten-year survival rates after valve-preserving root replacement are superior to survival rates after the Bentall operation With a low rate of valve-related complications valve-preserving root replacement has become an attractive alternative composite replacement of the valve and aorta.
20 Reimplantation Remodeling
21 Fries et al. JTCVS 2006; 100;132:32-37
22 Sinutubuar junction remodeling
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