Aortic valve repair: When and how to employ this novel approach?
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1 Aortic valve repair: When and how to employ this novel approach? Konstadinos A Plestis, MD System Chief of Cardiac Thoracic and Vascular Surgery Main Line Health Care System Professor Sidney Kimmel Medical College Thomas Jefferson University
2 Aortic Valve
3 Normal Aortic Valve Aortic cusps Aortic annulus Valsalva sinuses Commissures Sinotubular junction
4 The functional aortic annulus (FAA) STJ AVJ
5 Aortic Valve Regurgitation Khourhy Classification Functional Annular dilatation: type 1 Leaflet Prolapse: type 2 Leaflet Restriction: type 3
6 Mechanism of Aortic Regurgitation ANNULAR DILATATION - Type 1 STJ dilatation STJ+AVJ dilatation AVJ dilatation
7 Mechanism of Aortic Regurgitation CUSP PROLAPSE Type 2
8 Aortic Valve Repair for Aortic Regurgitation
9 Type Ia: Sinotubular dilatation Sino-tubular Junction dilatation
10 Type Ib: Aortic root aneurysm Aortic root aneurysm
11 Type Ib: Aortic root aneurysm Aortic root aneurysm
12 Type Ib: Valsalva Sinus Aneurysm Sinus of Valsalva aneurysm
13 Type 1c: Annular dilation Annular dilatation
14 Type Id: Cusp perforation Cusp perforation
15 Type Id: Cusp perforation Leaflet perforation
16 Type II: Flail aortic cusp Cusp prolapse
17 Type II: Flail aortic cusp Cusp prolapse
18 Type II: Partial cusp prolapse Cusp prolapse
19 Type II: Partial cusp prolapse Cusp prolapse
20 Type II: Partial cusp prolapse Cusp prolapse
21 Type III: Heavily calcified valve Cusp restriction
22 Type III: Heavily calcified valve Cusp restriction
23 Type III: Heavily calcified valve Cusp restriction
24 Anatomy of the Root
25 Effective Height
26 Effective Height Schafers H.-J. et al.; J Thorac Cardiovasc Surg 2006;132:
27 Isolated leaflet prolapse
28 Aortic Leaflet Plication
29 Subcomissural annuloplasty
30 Indications for Aortic Valve Repair Tricuspid or bicuspid aortic valves Aortic Valve Regurgitation Valve leaflets without calcification, fibrosis or multiple fenestrations Root Aneurysm Selective endocarditis cases
31 Bicuspid Aortic Valve Repair
32
33
34
35 Mini Sternotomy
36 Mini Sternotomy
37 Bicuspid Aortic Valve Repair Ascending Aneurysm Replacement
38 Case Presentation Bicuspid Aortic Valve Repair - Extension 31 yo female Asymptomatic Severe AI Bicuspid AV Ascending aortic aneurysm
39
40 Bicuspid Aortic Valve Repair Endocarditis 32 yo male Endocarditis Bicuspid AV NCC perforation Severe AI Annular dilatation
41
42 Aortic Valve Repair Outcomes Outcomes n=157 Age 59±15 Males 116 (74%)
43 Aortic Valve Repair Tricuspid AV % Bicuspid AV 26 17% Endocarditis 8 5%
44 Concomitant Procedures David procedure 23 15% Total Arch Replacement 6 4% Hemiarch 31 20% MVR 9 6% CABG 20 13%
45 Complications Mortality 2 1.2% Stroke 4 2.5% New RI 3 1.9% PVS 22 14% PVS-Prolonged Ventilatory Support RI- Renal Insufficiency
46 Complications Bleeding 5 3% Afib 35 22% CHF 4 2% CHF- Congestive Heart Failure
47 Follow up Mean Follow up: 5 yrs Freedom from AI > 2+ : 93% Freedom from reoperation: 94%
48 Literature Review
49 Aortic Valve Repair El Khoury 2010 (n=122) BAV El Khoury 2012 (n=475) Schafers 2010 (n=640) Holubec 2014 (n=100) Svensson 2014 (n=720) Age Male Acute Dissection BAV TAV AI % 81% 73% 73% 87% N/A N/A 10% N/A N/A 100% 35% 32% 60% 100% 0% 65% 64% 40% 0% 43% 34% 47% 82% 85% Aortic Dilatation 14% 46% 39% 67% N/A AI and Dilatation 43% 19% N/A N/A N/A
50 Aortic Valve Repair El Khoury 2010 (n=122) BAV El Khoury 2012 (n=475) Schafers 2010 (n=640) Holubec 2014 (n=100) Svensson 2014 (n=720) Raphe Repair 80% N/A N/A N/A Yes Cusp Prolapse Repair 65% N/A 83% 70% Yes Annuloplasty 42% 32% N/A 47% Yes Reimplantation 34% 41% 50% 12% N/A Remodeling 10% 10% N/A 44% N/A
51 Aortic Valve Repair El Khoury 2010 (n=122) BAV El Khoury 2012 (n=475) Schafers 2010 (n=640) Holubec 2014 (n=100) Svensson 2014 (n=720) Mortality 0% 0.8% 3.4% 0.8% 0.4% Stroke 0.8% 1.1% N/A N/A 0.3%
52 Freedom from Moderate or Severe Aortic Insufficiency Aortic Valve Repair El Khoury 2010 (n=122) BAV El Khoury 2012 (n=475) Schafers 2010 (n=640) Holubec 2014 (n=100) Svensson 2014 (n=720) 1 year 98% 3 years 84% 5 years 10 years 94% 91% 87% 51% 85% 81%
53 Freedom from Reoperation Aortic Valve Repair El Khoury 2010 (n=122) BAV El Khoury 2012 (n=475) Schafers 2010 (n=640) Holubec 2014 (n=100) Svensson 2014 (720) 1 year 98% 95% 5 years 94% 94% 93% 89% 87% 10 years 83% 86% 86% 87% 78% 15 years 64%
54 Long Term Survival Aortic Valve Repair El Khoury 2010 (n=122) BAV El Khoury 2012 (n=475) Schafers 2010 (n=640) Holubec 2014 (n=100) Svensson 2014 (n=720) 1 year 5 years 10 years 20 years 99% 99% 93% 92% 94% 97% 73% 80% 94% 82%
55 Conclusions Aortic valve repair has evolved significantly Results are reproducible 10 year outcomes are excellent
56 Thank You
57 Patch Repair
58 Central Cusp Plication Technique
59 Free Margin Resuspension with 7/0 PTFE suture
60 Minimally Invasive Procedure Excision of the vegetations of the conjoined leaflet Repair of perforation of NCC Free edge plication of conjoined leaflet Annuloplasty to 25 mm
61
62 Type II: Whole cusp prolapse Cusp prolapse
63 Type II: Whole cusp prolapse Cusp prolapse
64 Type II: Whole cusp prolapse Cusp prolapse
65 Case Presentation Isolated Tricuspid Valve Repair 45 yo male Increasing SOB Severe AI Rupture of fenestration Leaflet prolapse
66 Procedure Aortic valve repair Patch of the fenestration Free edge plication Subcomissural annuloplasty MV Repair
67
68
69
70 Case Presentation AV repair, External Annuloplasty 61 yo male Increasing shortness of breath
71 Preoperative Diagnosis Severe aortic valve regurgitation Bicuspid aortic valve
72 Procedure Aortic valve repair Conjoined left and right leaflets Free edge plication Circumferential external annuloplasty Sinotubular junction fixation
73
74
75 Comorbidities Hypertension % Diabetes 15 10% COPD 21 13% Renal Insufficiency 13 8% Stroke 13 8%
76 Aortic Valve Repair Emergent 24 15% Urgent 27 16% Redo 10 6%
77 Operative times Pump time 169±56 Cross Clamp time 123±52
78 Blood Utilization PRBC 2.0±3.0 FFP 1.5±2.0 Platelets 1.4±2.2 Cryoprecipitate 1.5±3.6
79 Aortic Valve Repair El Khoury 2010 (n=122) BAV El Khoury 2012 (n=475) Schafers 2010 (n=640) Holubec 2014 (n=100) Svensson 2014 (n=720) CPB N/A CC N/A 93 49
80 Tricuspid Aortic Valve Repair
81
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