Indications and Late Results of Aortic Valve Repair
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1 Indications and Late Results of Aortic Valve Repair Prof. Gebrine El Khoury Department of Cardiovascular and Thoracic Surgery Cliniques St. Luc Brussels, Belgium
2 Aortic Valve Repair Question # 1 Can the valve be repaired? Quesiton # 2 Should the valve be repaired?
3 Pre-requisites for Valve Repair Understanding of Functional Anatomy and Pathophysiology Quality of Tissue Reproducible Surgical Techniques Durable Outcome
4 Pathophysiology of AI: What do we know? Conclusion: The causes of pure AR severe enough to warrant isolated AVR are diverse. The most common category in this study was cause unclear
5 Classification of Aortic Insufficiency Apply to all anatomic subtypes of AI Clarify and provide insight into mechanism Provide a standard communication tool between cardiologists, surgeons, anesthesiologists Guide the potential surgical treatment Assess the long-term efficacy of different types of surgical repair
6 The Functional Aortic Annulus
7 STJ Sino-tubular Junction; SCA Sub-Commissural Annuloplasty
8 A Functional Approach to Aortic Insufficiency Type I : Dysfunction normal cusp motion Lesions Ia : sino-tubular junction dilatation Ib : STJ + sinuses dilatation Ic : annular dilatation Id : cuspal defect
9 A Functional Approach to Aortic Insufficiency Type I : Dysfunction normal cusp motion Lesions Ia : sino-tubular junction dilatation Ib : STJ + sinuses dilatation Ic : annular dilatation Id : cuspal defect
10 Type I : A Functional Approach to Aortic Dysfunction normal cusp motion Insufficiency Lesions Ia : sino-tubular junction dilatation Ib : STJ + sinuses dilatation Ic : annular dilatation Id : cuspal defect
11 A Functional Approach to Aortic Insufficiency Type I : Dysfunction normal cusp motion Lesions Ia : sino-tubular junction dilatation Ib : STJ + sinuses dilatation Ic : annular dilatation Id : cuspal defect
12 A Functional Approach to Aortic Insufficiency Type II : Dysfunction excess cusp motion Lesions Excess cuspal tissue Commisural disruption
13 A Functional Approach to Aortic Insufficiency Type III : Dysfunction restricted cusp motion Lesions Fibrous thickening Calcification
14 Assessment of Tissue Quality
15 Aortic Valve Pathology Pure aortic regurgitation - Aortic aneurysm - Bicuspid aortic valve - Degenerative leaflet prolapse - endocarditis - autograft failure - acute aortic dissection and commissural disruption
16 Patient Selection: Pathology Pure Aortic Regurgitation: - Aortic aneurysm - Bicuspid aortic valve - Degenerative leaflet prolapse - Autograft failure - Endocarditis - Acute aortic dissection and commissural disruption
17 Patient Selection: Pathology Pure Aortic Regurgitation - Aortic aneurysm - Bicuspid aortic valve - Degenerative leaflet prolapse - Autograft failure - Endocarditis - Acute aortic dissection and commissural disruption
18 Patient Selection: Pathology Pure Aortic Regurgitation - Aortic aneurysm - Bicuspid aortic valve - Degenerative leaflet prolapse - Autograft failure - Endocarditis - Acute aortic dissection and commissural disruption
19 Patient Selection: Pathology Pure Aortic Regurgitation - Aortic aneurysm - Bicuspid aortic valve - Degenerative leaflet prolapse - Autograft failure - Endocarditis - Acute aortic dissection and commissural disruption
20 Patient Selection: Pathology Pure Aortic Regurgitation - Aortic aneurysm - Bicuspid aortic valve - Degenerative leaflet prolapse - Autograft failure - Endocarditis - Acute aortic dissection and commissural disruption
21 Reproducible Surgical Techniques
22 Principles of aortic repair The goal of aortic repair is to restore a normal surface of coaptation 1. Repair or preserve the cuspal tissue 2. Restore the proximal and distal borders of the native stent
23 Type Ia repair : Sino-tubular junction remodeling Aortotomy Valve analysis Sizing Prosthesis implantation Final result Subcommissural annuloplasty Sino-tubular junction dilatation
24 Type Ib repair : Aortic root remodeling Aortotomy Root dissection Prosthesis implantation Prosthesis implantation Final result Aortic root aneurysm
25 Type Ib repair : Aortic root reimplantation Aortotomy Root dissection Prosthesis implantation Prosthesis implantation Final result Aortic root aneurysm
26 Gebrine El Khoury - The Functional Approach of the Aortic Valve Repair: From Mitral to the Aortic Type II repair Triangular ressection Plication Free edge reinforcement Free edge reinforcement Cuspal prolapse
27 Free Margin Plication
28 Free Margin Resuspension (with CV-7 PTFE suture)
29 Type Ia + II repair Valve analysis Subcommissural annuloplasty Prosthesis implantation Sino-tubular junction dilatation
30 Type Ib + II repair Evaluation Resection of the aortic root Reimplantation Cusp repair Aortic root aneurysm
31 Bicuspid Aortic Valve
32 Root disease Leaflet disease
33
34 Cusp Anatomy Type 0 Type 1 (prolapsing) Type 1 (restrictive) (Sievers et al. JTCVS 2007)
35 Algorithm for Systematic Approach to Bicuspid Aortic Valve Repair Aortic Root Size < 4.5 cm 4.5 cm Aortic Tissue Quality Good Poor Root Replacement (Reimplantation Technique) Cusp Repair Cusp Anatomy Type 0 Type 1 Fibrous/ Prolapsing Raphé Preservation/ Shaving Quality of Raphé Calcified/ Restrictive Raphé Resection Cusp Repair Sub-Commissural Annuloplasty Inadequate Pericardial Patch for Cusp Restoration Quantity of Cusp Tissue Adequate Primary Approximation Assessment and Repair of Cusp Prolapse - Free Margin Plication/Resection - Free Margin Resuspension
36
37 Are the results durable?
38 Supracoronary Ascending Aortic Aneurysms (Type 1A)
39 Freedom from AV Reoperation Freedom from AV Reoperation Months No. at risk
40 Valve Sparing Root Replacement (Type 1b) Effects of preoperative aortic insufficiency on outcome after aortic valvesparing surgery. de Kerchove L, Boodhwani M, Glineur D, Poncelet A, Verhelst R, Astarci P, Lacroix V, Rubay J, Vandyck M, Vanoverschelde JL, Noirhomme P, El Khoury G. Circulation Sep 15;120(11 Suppl):S120-6.
41 Freedom from AV Reoperation - Replacement % AV replacement AV reoperation 8 years 93±5% 90±7% Months patients at risk:
42 Cusp Prolapse Repair (Type 2)
43 Freedom from AV Reoperation % Isolated Associated 8 years 100% 93 ± 4% Years No. at risk Isolated Associated
44 Bicuspid Aortic Valve Repair Repair of regurgitant bicuspid aortic valves: A systematic approach. Boodhwani M, de Kerchove L, Glineur D, Rubay J, Vanoverschelde JL, Noirhomme P, El Khoury G. J Thorac Cardiovasc Surg May 18.
45 Overall Survival % years 97 ± 2% Months No. at risk
46 Freedom from Aortic Valve Reoperation % AV Reoperation AV Replacement Months 5 years 8 years 94 ± 2% 83 ± 5% 96 ± 2% 90 ± 5% Late AV Reoperation 98 ± 2% 87 ± 5% No. at risk
47 Aortic Valve Repair: Why Not? Question # 1 Can the valve be repaired? Quesiton # 2 Should the valve be repaired?
48 Bioprosthetic Valves:
49 Durability David et. al. Ann Thorac Surg 2010;90:775-81
50 Durability David et. al. Ann Thorac Surg 2010;90:775-81
51 Durability McClure et. al. Ann Thorac Surg 2010;89:1410 6
52 Durability McClure et. al. Ann Thorac Surg 2010;89:1410 6
53 Patient Selection: Age Institutional experience of 476 patients: Mean age 53 ±16 (range 6-86 years) <65 years: 74% >65 years: 26% >80 years: 11%
54 Durability of Repair vs. Replacement Bioprosthetic valves degenerate faster in younger patients Age < 50 : 3.7% / pt-year Age : ~2% / pt-year (Jamieson WR J Thorac Cardiovasc Surg 2005;130: )
55 Valve Related Complications Thromboembolism: Bioprosthesis = Mechanical : 1-2% / pt-year Higher following Mechanical Bentall (upto 10%/pt-yr) Repair : 0.4%/ pt-year Bleeding Events Mechanical valves : ~2%/ pt-year Endocarditis Very low with repair (~0.1%/pt-year)
56 Conclusion Should the Aortic Valve be repaired? 1. If a durable repair is feasible 2. If the patient stands to benefit from reduced valve-related complications Why Not?
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