PPM: How to fit a big valve in a small heart

Transcription

1 PPM: How to fit a big valve in a small heart Hani K. Najm MD, Msc, FRCSC, FRCS (Glasgow), FACC, FESC King Abdulaziz Cardiac Centre National Guard Health Affairs Riyadh, Saudi Arabia GHA meeting Muscat Jan, 2012

2 Patient-prosthesis mismatch Effective orifice area index= Effective orifice area/bsa(sq.m) 2.0 or above: Normal 0.67 : Severe stenosis Rahimtoola first described 1978 Pibarot and Dumensnil (1998) defined PPM to be effective orifice area indexed to BSA of 0.85m 2 /m 2 or less

3 PPM High residual trans-valvular gradient may result in: Decreased LV mass regression Operative mortality Long term survival symptomatic benefit

4 Selection of prosthesis: Pibart and Dumesnil JACC 2000;36: BSA 0.85 cm 2 /m 2 = EOA required to avoid severe PPM. Selection of most suitable type and size of prosthesis according to EOA. ICVTS 2009;9:

5 OPTIONS If PPM is present on calculation Implant prosthesis with a larger EOA : Modern bi-leaflet mechanical prosthesis Newer bioprostheses. Implantation of stentless prosthesis/ homograft/ sutureless valve Aortic root enlargement

6 How are valves measured Manufacturer s labelled sizes refers inconsistently to: Diameter of external sewing ring Diameter of mounting ring Diameter of internal orifice mechanical valves stented xenografts stentless xenografts and allografts JTCVS 2003;126:313 6

7 GOA is measured in vitro indicating internal diameter of the valve. EOA is validated in clinical practice and calculated using echocardiography Heart 2006;92:

8 Not all similarly labeled valves are the same!!

9 EOA Comparison of EOAs for commonly implanted prosthetic valves.

10 Gradient Comparison of mean pressure gradients for commonly implanted prosthetic valves.

11 Heart 2006;92:

12 Operative options for small aortic root Posterior annular enlargement: Nicks technique. Manouguian technique. Anterior annular enlargement: Rastan-Konno operation. Root replacement Homografts Stentless xenografts Ross operation alone or Konno-Ross operation. Apico-aortic conduit.

13 Decision to enlarge aortic root It is usually taken by the surgeon operating and on a feeling that the annular size is smaller than required for that patient depending on : Pt age Comorbid conditions Anatomy of the aortic root Surgeon s judgment Surgeon s comfort level

14 Posterior annular enlargement Manouguian technique Nick s technique

15 Posterior Root Enlargement

16 Manouguian approach Aortotomy extended towards aortic annulus related to the middle of non-coronary cusp (NCC). Incision extended across aortic annulus and then across mitral annulus and into the body of anterior mitral leaflet (AML). Aortic annulus opens up in the form of inverted-v with apex towards AML.

17 Manouguian approach II A v-shaped dacron patch sutured to the edges of this incision thus enlarges aortic annulus by 2-3 cm. Interrupted sutures for holding prosthesis passed circumferentially into aortic annulus except posteriorly where they are passed through dacron patch.

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23 Nick s s approach Oblique aortotomy extended towards and across the commissure between LCC and NCC, thus dividing the annulus. Incision extended vertically across the triangular area between two cusps and thereafter into the aortic-mitral fibrous continuity.

24 Nick s s approach II Tear-drop shaped Dacron patch is sutured to the defect to enlarge the posterior annulus. Valve sutures are brought from outside the patch at annular level. Rest of the patch is used to close aortotomy incision.

25 Small aortic root with sub-aortic stenosis Challenging problem

26 Subaortic Tunnel-like stenosis

27 Tunnel-like LVOT

28 Aortoventriculoplasty (Rastan/Konno)

29 Rastan Konno Procedure

30 Rastan Konno Procedure

31 Rastan Konno Procedure

32 Aortoventriculoplasy (Rastan/Konno) IVS Incision towards the lv apex. patch on the IVS that continue on the aortotomy. AVR with mechanical valve Patch closure right ventriculotomy

33 Ross-Konno & Modified Konno

34 Ross Konno Combine the Rastan- Konno and a pulmonary Autograft like in the Ross procedure.

35 Ross/Konno procedure

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37 Bypassing difficult aortic root Apico-aortic valved conduit

38 Apico-aortic conduit It is an alternative when there is: Severe left ventricular hypertrophy. Diminutive left ventricular size. Diffuse thickness of the IVS. Multiple aortic valve replacements with small aortic root.

39 Apico-aortic conduit

40 Actuarial survival in patients with Prosthesis mismatch 2981 patients 227 had EOA/ BSA ratio 0.75 cm²/m². Rao, V. et al. Circulation 2000;102:III-5-III-9

41 Freedom from valve-related mortality in patients with prosthesis mismatch (EOA/BSA<=0.75 cm2/m2) Rao, V. et al. Circulation 2000;102:III-5-III patients 227 had EOA/ BSA ratio 0.75 cm²/m².

42 Actuarial survival in patients with prosthesis mismatch as defined by indexed ID ratio of <=10 mm/m2 Rao, V. et al. Circulation 2000;102:III-5-III-9

43 Conclusions of Study Rao, V. et al. Circulation 2000;102:III-5-III-9 Overall mortality not effected. Valve related mortality higher with PPM. Survival advantage only after 7 th postoperative year. Effect of PPM on survival is controversial.

44 De ning PPM and Its Effect on Survival in Patients With Impaired Ejection Fraction David A. Cotoni, DO, Robert T. Palac, MD and Lawrence J. Dacey, MD Retrospective study Ann Thorac Surg 2011;91: patients with EF < 45% or less PPM was defined as Non significant if indexed GOA was 1.2cm²/m² or indexed EOA 0.85 cm²/m²

45 Risk-adjusted survival stratified by patient-prosthesis prosthesis mismatch (PPM) definition Risk adjusted overall survival was the same for patients with PPM and without PPM throughout nine years of follow up. Cotoni D. A. et al.; Ann Thorac Surg 2011;91:

46 with small aortic roots 540 AVR with <21 mm prosthesis 172 AVR+ARE (50% had 23mm prosthesis) F/U for 5.2 y (3730 pt-years)

47 Aortic cross clamp was 9.9 min longer in AVR+ARE No difference in reopening, stroke or mortality Post op Lower gradient Larger IOA Lower PPM No difference in survival

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49 Aortic Valve Replacement With 17-mm Mechanical Prostheses: Is Patient Prosthesis Prosthesis Mismatch a Relevant Phenomenon? Andrea Garatti, MD, Francesca Mori, MD, Lorenzo Menicanti, MD Division of Cardiac Surgery, Milan & Foggia, Italy Annals of Thoracic Surgery 2011;91:71 8 Early and long term mortality was similar in two groups Mean and peak gradients and LV mass regression was similar in both groups.

50 Implantation of 17 mm mechanical valve Conclusions PPM not an independent risk factor for early or late Mortality. No effect on clinical improvement or LV mass regression.

51 Patient-Prosthetic Mismatch Four Critical Considerations 1.Patients with high risk of PPM are already high risk for surgery due to small aortic root, elderly females (common), severe CAD, impaired ventricular function. It is difficult to discriminate between patient related and prosthesis related confounding factors. 2.IEOA is functional measurement dependant on the characteristics of prosthesis and left ventricular and aortic outflow tract and cardiac output 3.Difference between IEOA and indexed GOA of the prosthesis and lack of correlation between transvalvular gradients and GOA. 4.Discrepancy between manufacturer labelled and actual diameter of the prosthesis (EHJ 2006:27; )

52 Conclusions Small aortic roots still poses a difficult problem to the surgeon There is no clear objective data to suggest the exact indication for ARE The decision to enlarge the root is dependent on the surgeon evaluation and experience Presence of PPM may increase gradients and reduce IEOA but does not affect survival

53 Conclusions In Infants Small root with no SAS, Ross procedure Small root with SAS Ross/Konno In Children Small root with no SAS, Ross procedure Small root with SAS Ross/Konno or Konno /Rastan In Adults Small root, large BSA Ross or homograft or AVR+ARE Small root, small BSA (<1.5) AVR

54 Thank you