Late results of aortic root repair & replacement. John Pepper Imperial College and Royal Brompton Hospital, London, UK.
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1 Late results of aortic root repair & replacement John Pepper Imperial College and Royal Brompton Hospital, London, UK.
2 REPLACEMENT OF ASCENDING AORTA AND ROOT Interposition graft Valve sparing VR + graft Bentall button
3 Marfan:Aortic Root Replacement [Gott VL. Ann.Thorac.Surg. 2002; 73: 438] No. of patients 30-day mortality % Elective Urgent TOTAL
4 271 Marfan patients after ARR [Gott VL Ann.Thorac.Surg. 2002;73:438] Survival 89% 81% 76% 67%
5 Freedom from thromboembolism Freedom from thromboembolism [Gott VL. Ann.Thorac.Surg. 2002;73:438] 96% 93%
6 Aortic valve repair in Marfan s syndrome Valve conserving operations are feasible Early and long term results are encouraging Results are better in the absence of dissection Prophylactic operation is warranted in high risk patients
7 CMR of the aorta
8 Reimplantation Valve sparing Remodelling
9 Late results of valve sparing [Yacoub M. JTCS 1998; 115: 1080] Actuarial survival 1yr 5yrs 10yrs 15yrs Acute dissection N=49 Ch. Aneurysm N=
10 Valve sparing: acute vs. chronic [Murashita T. Eur.J.CT. Surg. 2001; 20: 967] Preop. AR > Grade 2 Preop. AR > Grade 3 Replacement of aortic valve Reop. on preserved valves Acute N=55 Chronic N==38 P 16 (29%) 14 (37%) (13%) 11 (29%) (7%) 8 (21%) /43 2/27 (7%) 0.077
11 Late results of AV sparing Era: for ARA [David TE. 2007] 220 patients for Ao.Root Aneurysm (ARA) Mean age: 47 +/- 16; Mean FU: 5.2 yrs Aetiology: Marfan - 40% Type A Dissection - 12% Bicuspid AV - 6%
12 Late results of AV sparing for ARA [David TE. 2007] 1 year 5 years 10 years FF Death 97% 92% 88% FF AVR FF ¾ AR Remodel N=69 Reimplant N=
13 Durability of AV repair [Cameron D Johns Hopkins] Time Bentall Remodelling Reimplantation 1yr 100% 97.4% 100% 5yr 95.8% 86.1% 100% 8yr 95.8% 86.1% 100%
14 Aortic valve repair RBH patients Average age 62.4 (28-79) 8 deaths all in Type A Dissection
15 Aortic valve repair RBH April April 2010 Clinical Marfan Non- Marfan Acute A Dissection N Chronic A Dissection Operation Remodelling Remodelling Resuspension Resuspension 30-day Late 1-6yrs
16 Marfan - ARR and valve sparing: meta-analysis [Angeloni E. 2010] Procedure ARR VSRR P N F/U yrs Reintervention rate 0.3 T/E rate 0.7 Reimplantation Remodelling [ ] [ ] 1.3 [ ] 0.3 [ ]
17 Repair of the bicuspid aortic valve [Ashikhmina E. JTCS 2010; 139: 1395]
18 BAV repair: freedom from reoperation Author FU yrs N Age mean 1yr 5yr 10yr Alsoufi NA Casselman NA Davierwala NA Fraser NA NA Kin NA Ashikhmina
19 Should VSRR be offered to BAV or severe AR? [Badiu CC. Eur.J.Cardiothorac.Surg 2010] Remodelling: 28 [27.5%] Reimplantation: 30 [29.4%] 5-year survival for all patients: /- 1.5% BAV TAV Mod/severe AR N
20 Should VSRR be offered to BAV or severe AR? [Badiu CC. Eur.J.Cardiothrac.Surg 2010] ALL TAV + mild/mod AR TAV + severe AR FF reop. on AV 92% 100% 82 +/- 7.5% FF from AR 73 +/- 7.7% /- 16.4%
21 A word of caution Aortic root replacement is the gold standard Valve sparing procedures are evolving Indications uncertain Learning curve Long-term antiplatelet therapy advised Risk of redo root replacement
22 Beauty in Nature gives Man s senses the chance to be skilful Bertolt Brecht
23
24 Repair of regurgitant BAV: a systematic approach [Boodhwani M. JTCS 2010; 140: 276] N = 122 Mean age 44 (+/-11) Elective repair: AR 43% ARD 14% Both 43%
25 Repair of regurgitant BAV: a systematic approach [Boodhwani M. JTCS 2010; 140: 276] 5 years 8 years Survival 97% +/-3% FF re-operation 94% +/- 2% 83% +/- 5% FF AV repl. 96% +/- 2% 90% +/- 5% FF t/e 96% +/- 2% FF AR grade ll 94% +/- 3%
26 Clinical and Echo outcomes after BAV repair [Boodhwani M. JCTS 2010; 140: 276]
27 Aortic Wall Abnormalities in Coarctation [Oliver JM. JACC 2004; 44: 1641] % SURG PCI MED Desc.Ao Overall 0 Asc.Ao < >39 TAV BAV
28 Response to Glutaraldehyde preserved valves Three simultaneous processes Post-surgical wound healing Non-specific (foreign body) inflammation Immune-mediated rejection with associated inflammation
29 Natural history of TAA [Elefteriades JA. Ann.Thorac.Surg. 2002;74: S1877] Index cm/m 2 Risk of rupture, dissection or death % % > %
30 Views of the aortic valve
31 Aortic ring to standardise repair [Lansac E. EJCTS 2010; 38: 147]
32 A systematic approach [Gebrine El Khoury 2010] <45mm Aortic root size >45mm Aortic tissue quality Poor Leaflet repair Root replacement Good Leaflet repair Sub-commissural annuloplasty
33 A systematic approach [Gebrine El Khoury 2010] Leaflet anatomy Fibrous/prolapsing Quality of raphe Calcified/ restrictive Raphe Preservation shaving inadequate Pericardial patch Quality of Leaflet tissue Raphe resection adequate Primary approximation Assessment and repair of prolapse Free margin plication Free margin resuspension
34 BAV No indication for operation FU 6-12mts Indication for operation Acceptable Morphology l + ll Non-acceptable Morphology lll Ao.wall AA>45mm or Di >2.75 Dilated sinus Ao.wall AA>45mm or Di >2.75 Dilated sinus YES NO YES NO 1.BAV reimplantation 2.BAV repair + AA repl. 3. Bentall 4. BAVR + AA repl. 1. Attempt BAVR 2. BAVR 1. Bentall 2. BAVR + AA repl. BAVR
35 Stented Valve Mosaic Stentless Valve Freestyle
36 Effective orifice area index (EOA index) EOA index (cm 2 /m 2 ) 1.6 *** overall p between groups < stentless stented Pre Op (n=175) 6 Months (n=150) 12 Months (n=111) 26% increase in EOA index stentless vs stented group
37 Peak aortic gradient (Echo) Peak aortic gradient (mmhg) 120 Overall p value between groups < stentless stented Pre Op (n=175) 6 Months (n=150) 12 Months (n=111) 58% reduction in peak aortic gradient in the stentless vs stented group
38 Conclusions: CMR CMR has corroborated echo data using a much smaller sample CMR probably provides better estimation of these parameters CMR well tolerated
39
40 Failure model of Bio-prostheses Schoen FJ, et al. Hum Pathol, 1985;16:
41 Cumulative survival of 40 year old after AVR [Grunkemeier GL. J.Ht.Valve Dis. 1999; 8: 466] Survival AVR Healthy Time in years
42
43 Determinants of valve sparing Diagnosis Operation type Immediate post-op AR Threshold for reoperation
44 Survival Actuarial Survival (n = 82) 1yr 5yr 10yr yr = 93.2% 5 yr = 87.3% 10 yr = 84.3% No at risk 1 yr = 65 5 yr = yr = 17 Days post op
45 Actuarial Survival (n = 82) Survival Chronic Aneurysm No at risk 1 yr = 65 5 yr = yr = yr 5 yr 10 yr Chronic dissectio Acute dissection Days post op
46 Asymptomatic vs. Symptomatic (n = 82) Survival No at risk 1 yr = 65 5 yr = yr = yr 5 yr 10 yr Asymptomatic (n = 37) Symptomatic (n = 45)
47 Effect of pre operative B Blockade on surviva Survival B Blockers (n =47) No at risk 1 yr = 65 5 yr = yr = yr 5yr 10yr No B Blockers (n = 35)
48
49
50 Factors influencing growth in dilated aortic Factor segments [Bonser RS. Heart 2000; 84: 283] Median difference 95% CI P Thrombus TIA/stroke Smoking PVD
51 Aortic stenosis
52 Poor LV, Aortic stenosis, Previous MI (subendocardial mainly white arrows - but transmural at apex with apical thrombus red arrow)
53 Poor LV, Aortic stenosis, Previous MI ( white arrows )
54 Late results of AV sparing for ARA [David TE. JCTS 2006; 132: 347] Era: patients for Ao.Root Aneurysm (ARA) Mean age: 47 +/- 16; Mean FU: 5.2 yrs Aetiology: Marfan - 40% Type A Dissection - 12% Bicuspid AV - 6%
55 Late results of AV sparing for ARA [David TE. JCTS 2006: 132: 347] 1 year 5 years 10 years FF Death 97% 92% 88% FF AVR FF ¾ AR Remodel N=69 Reimplant N=
56 Aortic valve repair RBH patients Av age 51.6 [24-73] 3 deaths all in acute Type A dissection
57 Aortic valve repair RBH Clinical Marfan Non- Marfan Acute A Dissection N Chronic A dissection Operation Remodelling Remodelling Resuspension Resuspension 30-day Death Late re-op
58 Surgical intervention criteria for thoracic aortic aneurysms [Coady MA. Cardiol Clin 1999; 17: 827] 140 9% 10% 18% 28% TOTAL D/R >6.0 Thoracic aortic size (cm)
59 Aortic valve repair Bicuspid valve repair STJ tailoring Remodelling Reimplantation Commissure Leaflets Annulus SOV STJ
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