Failed Aortic Valve Repairs Lessons Learned

Transcription

1 Failed Aortic Valve Repairs Lessons Learned A. Stephane Lambert, MD, FRCPC Munir Boodhwani, MD, MMSc, FRCSC University of Ottawa Heart Institute Ottawa Ontario

2 No Disclosure

3 Why do repairs fail?

4

5 Basic Concepts AI is due to insufficient coaptation Goal of is to increase coaptation Restore/maintain geometry Need enough tissue/good quality tissue

6 How to define inadequate repair? AI and Beyond 1. Residual AI = Insufficient coaptation 2. Quality of coaptation Coaptation length Coaptation Surface Area Level of coaptation - Effective height 3. Geometry Cusp mobility Valve symmetry (tricuspid valve) Gradients (especially bicuspid)

7 186 pts, 18 mo. follow up. 41 pts had 3+ AI Multivariate analysis J Am Coll Cardiol Img 2009;2:931-9

8 le Polain de Waroux, J Am Coll Cardiol Img 2009;2:931-9

9 le Polain de Waroux, J Am Coll Cardiol Img 2009;2:931-9

10 Algorithm le Polain de Waroux, J Am Coll Cardiol Img 2009;2:931-9

11 Effective Height eh as an surrogate for cusp geometry Distance between tip of cusps and plane of VAJ Normal 9.5 mm Schäfers et al, J Thor Cardiovasc Surg, Aug 2006

12 eh correlates with outcome 651 post AV repair Mean follow up 50 month Severity of AI None Mild Moderate Severe eh 9.8 ± 0.9 mm 9.4 ± 1.1 mm 7.9 ± 1.4 mm 6.0 ± 1.0 mm Bierbach et al. Euro J Cardio Thor Surg 2010

13 eh correlates with outcome eh < 9 mm n = 154 eh 9 mm n = 497 None 25 (16%) 309 (62%) Mild 85 (55%) 186 (37%) Moderate 41 (27%) 2 (004%) Severe 3 (0.02%) 0 (0%) Bierbach et al. Euro J Cardio Thor Surg 2010

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15 Example 1 65 y.o male (76kg) CAD with CABG 2003 (all grafts patent) Recent dyspnea: NYHA class II TTE: Severe (4+) AI; 6 cm aortic root aneurysm; LVEF normal

16 Pre Tricuspid AoV Severely dilated Aortic Root Equilateral Triangle Severe AI Central Origin

17 Pre RCC slightly prolapsed Post cusp restricted (LCC vs NCC?) Severe Root Dilatation Severe AI Eccentric Jet Posteriorly Directed

18 Pre 3D En face view with tilted view Cusps are taut c/w severe root dilatation

19 Pre RCC prolapse worse vs. NCC NCC mobility not bad LCC mobility decreased

20 Pre VAJ 2.3 cm SoV cm STJ 5.4 cm Asc Ao cm (asymmetric?)

21 Analysis Structure Tricuspid Valve RCC prolapse with LCC Restriction Severe root dilatation (asymmetric?) Function Type 1B? Type 3 Is the restriction structural or functional?

22 Repair

23 Post #1

24 What does the surgeon need to know? How much AI (loading conditions) Jet origin (central vs commissural) Jet direction (central vs. eccentric) Cusp motion? Root geometry? Specific coaptation lines? WHAT IS THE MECHANISM? WHERE IS THE PROBLEM?

25 Post #1 Mild to moderate AI Eccentric jet now directed ANTERIORLY

26 Post #1 Root symmetrical Originating from LCC/RCC coaptation line

27 Post #1? Sagging of the LCC

28 Post #1 N L Jet begins at RCC-LCC coaptation and extends anteriorly towards the NCC-RCC commissure

29 Post #1

30 Analysis Mild to moderate (2+) AI Originating from RCC-LCC coaptation Eccentric jet Probable mechanism: relative LCC prolapse

31 Return to Bypass Free margin plication

32 Post #2 Still tiny leak at LCC RCC commissure

33 Post #2 Mild residual AI Same origin, but jet is now CENTRAL

34 Post #2 Coaptation length: 6 mm Effective Height: 9.5 mm VAJ diameter 21 mm

35 Post #2

36 Analysis Level of coaptation well above VAJ Trace AI central Coaptation length > 4mm (6 mm) Effective height > 9mm (9.5 mm) VAJ diameter 21 mm No significant gradient

37 Lessons Learned Preoperative indicators of what cusp repair will be required Impact of changes in aortic root geometry on cusp function Assessment of cusp anatomy following valve sparing surgery

38 Case 2 85 y.o. male, Fairly active, no significant co-morbidities Severe (4+) AI Progressive LV dilatation, LVEDD 70 mm; good LV systolic function.

39 Pre Thickened cusps RCC prolapse? Restricted posterior cusp Posteriorly directed jet

40 Pre Tricuspid valve Central origin of jet

41 Pre VAJ SoV STJ Asc Ao cm 3.7 cm 3.9 cm 3.6 cm

42 Analysis Tricuspid valve Thickened, somewhat restricted cusps Mild dilatation of STJ (Type 1A) Relatively normal VAJ RCC prolapse (Type 2) Thickened cusps (?Type 3)

43 Repair

44 Post #1 Subcommissural Annuloplasty Free margin plication RCC Residual central jet

45 Post #1 Free margin plication on RCC Eccentric 4+ AI 2+ central AI Residual central coaptation defect

46 Analysis Residual AI Short length of coaptation Low effective height Elderly patient who would do very well with prosthesis

47 Final outcome: bioprosthesis

48 Lessons learned Poor tissue quality (Type 3) Low threshold for replacement in 85 y.o.

49 Example 3 35 y.o. active healthy male Presented 5 years ago with BAV & root aneurysm

50 Pre Type 0 BAV Posterior cusp larger than anterior cusp Mild calcification at lateral commissure Trivial AI arising from commissures

51 Pre Thin mobile cusps Aortic Root Aneurysm Minimal AI

52 Pre VAJ SoV STJ Asc Ao cm 6.2 cm 5.9 cm 3.2 cm

53 Analysis Type 0 bicuspid Asymmetric cusps, slight calcification Thin mobile cusps VAJ upper limit normal, SoV & STJ severely dilated (Type 1B)

54 Post #1 Valve sparing root replacement No AI Annulus 26 mm Return to CPB Severe billowing Good coaptation length (6 mm) Low Effective Height (3 mm)

55 Post #2 Free margin resuspension Still mild billowing Good coaptation length / effective height No AI

56 Level of coaptation (effective height) much higher above VAJ after free margin resuspension

57 Delayed Failure Patient presents 5 years later Severe AI Still healthy and active

58 Redo Pre Severe eccentric AI

59 Redo - Pre Thickened cusp edges (resuspension) Dilated VAJ (30 mm) Rest unchanged

60 Surgical findings

61 Final outcome: mechanical prosthesis

62 Analysis - Discussion Complex BAV repair Delayed VAJ dilatation Subcommissural Annuloplasty vs. Valve Sparing Root Replacement

63 SCA vs VAJ Navarra et al. European Journal of Cardio-Thoracic Surgery 2013

64 Thank you!