Transoesophageal echocardiography and decision making in valve surgery

Transcription

1 Transoesophageal echocardiography and decision making in valve surgery Intraoperative evaluation of the surgical results in aortic valve / root surgery Catherine Szymanski

2 Disclosures None

3 Sino-tubular junction The aortic annulus: a 3D structure Membranous septum Inter leaflets triangle 3D Aortic annular base 2D + 2D Sutton et al. ATS 1995 Anderson et al. ATS 1991

4 Dynamic anatomy of the aortic root Supravalvular: aortic dynamics Subvalvular: LV dynamics CHANGE IN AREA N = ISOVOLUMIC CONTRACTION max median min B C STJ AA Stressless opening of the aortic valve Maximise ejection AORTIC ROOT LEVEL Aortic Root = 2 functional compartments Aortic Aortic valve Root opening starts Expansion prior to starts ejection prior (2.1±0.5%) to ejection Lansac 2002 Systolic expansion of root volume ±2.7% Clover shaped aortic valve orifice Lansac 2001 Da Vinci 1508 Leyh Circulation 1999 Vortices = stressless valve closure Katawama 2008 Kilner Circulation 1993

5 4 diameters Pre-operative TEE STJ > Annulus Ratio = 1.2 ( ) ch= 4-5 mm eh= 9-10 mm Dilated 27.4± mm mm ch eh Long Axis ±1.4 mm Dilated 25 mm Transgastric 0 et 120 Short Axis 45 4 diameters Coaptation Direction of the jet Cusp number Origine of the jet Commisssure Analysis

6 Root phenotype Root aneurysm Valsalva 45 mm Supra coronary aneurysm Valsalva 40 mm Cusp motion Isolated AR All Ø 40 mm Normal (I) Prolaps (II) Retracted (III) AR zero Central jet Eccentric jet Carpentier A. JTCVS 1983, El Khoury et al curr opin cardiol 2005, Lansac et al EJCTS 2008

7 Coaptation and cusp motion Direction of the jet Central Excentric septum NC or LC prolaps Eccentric towards MV RC prolaps Bicuspid or tricuspid?

8 Coaptation and cusp motion Origin of the jet Central Large central jet Trivalvular prolaps Eccentric Rupture fenestration Central At whole coaptation Raphe calcifed

9 Bicuspid classification Sievers et al. JTCVS 2007

10 Expansibility of the aortic root Leygh 1999 Echo De Paulis 2002 Echo Varnous 2003 Echo Kazui 2004 Echo Maselli 2005 Echo Matsumori 2007 Echo De Heer 2011 CT scan N Zhu 2001 Echo Annular base 9.6±1.5% 7.7% 2.55% 5.7% 5.1% ( ) 6.8% 7±1.8% 4.6% 2.7% SoV 10.3±3.4% 4.4% 2.1% 4.3% 0.5% ( ) 3.7% 7.2±1.8% 2.1% 4% STJ 7.0±1.8% 5.3% 2.8% 5.4% 5.7% ( ) 5.9% 9.8±6.2% 1.7% 5% 5.7% 5.4% Aortic annulus and STJ expansion

11 What are the normal diameters of the aortic root? Roman 1987 Kim 1996 Nistri 1999 Varnous 2003 Maselli 2005 Babaee 2007 Tamas 2007 Soncini 2009 Bierbach 2010 Zhu 2011 N Annular Ø STJ Ø STJ/ annulus 24.5 (± 3) 27.5 (± 3) 23.4 (± 2.4) 28.1 (± 3.2) 22.7 (± 2.7) 24.7 (± 2.8) (± 3) 31.2 (± 3.7) 24.4 (± 4.1) 22.3±1,4 ( ) 25.4 (± 4.1) 26.7±2.2 ( ) 1.2±0.1 ( ) 21.8±2.4 21± 3 21,6 21±2,8 20,3±8,7 29.5±3.1 27± 4 27,3 25± 3,7 23.4±3, ,3 1,2 1,1 Dilated 35 mm Dilated 25 mm STJ> Annulus Ratio = 1.2 ( )

12 Parameters for valve coaptation STJ eh ch Aortic annular base ch= 4-5 mm eh= >9 mm Bierbach EJTCVS 2010 Tamas JHVD 2007

13 When to repair the aortic valve? Ascending aorta aneurysms Isolated AR Root aneurysm Supra coronary aneurysm Symptom Ø 55 mm idiopathic aneurysm Ø 50 mm bicuspid, coarctation, familial history Ø mm Marfan 2-5 mm/y Ø 45 mm aortic valve disease requiring surgery Symptom Asymptomatic and LVEF<50% and/or LVESD 50 mm (25 mm/m2) and/or LVEDD>70 mm Guidelines : AHA/ACC Circulation 2008, ESC Eur Heart J 2007, ACCF/AHA Circulation 2010

14 Valve sparing procedures Remodeling of the aortic root Yacoub 1983 Reimplantation of the aortic valve David Treatment of STJ dilatation + + Sinuses of Valsalva ± + Aortic Root expansibility (interleaflet triangles) - Supravalvular annuloplasty - Treatment of aortic annular base dilatation + Sub and supravalvular annuloplasty

15 Aortic valve dynamics after valve sparing Reimplantation Remodeling Controls Leyh RG. Circulation 1999 Fries. JTCVS 2006 Cusp motion and expansibility of the aortic root is best preserved 1) after Remodeling than after Reimplantation De Paulis. ATS ) with graft with neo- sinuses of Valsalva than without Ranga. ICVTS 2006 Furukawa. ATS 2004 Robiczek. Acta Chir Belg 2002 Grande allen. JTCVS 2000 Matsumori. ICVTS 2007 Aybeck. JHVD 2005 Markl. JTCVS 2005 Erasmi. JTCVS 2005 Kvitting. JTCVS 2004 Grande allen. JTCVS 2000 Robiczek. ACB 2002 De Paulis. ATS 2002 Furukawa. ATS 2004 Fries. JTCVS 2006 Ranga. ICVTS 2006 Katawama. JTCVS 2008 Erasmi. JTCVS 2005 Soncini. MEP 2009

16 Influence of valve sparing procedure on cusp coaptation? z [mm] Coaptation level is 14 systole lowered towards open aortic valve Soncini. MEP 2009, Pr C. Antona, with permission 12 annular base after both 10 types of valve sparing 8 procedures Nodulus of Arantius height time [s] Physiological Reimplantation Remodelling diastole closed valve Resuspension of the cusp effective Reduction of STJ induces symmetrical prolapse Reimplantation 3.8 mm Remodelling 3.3 mm Schäfers et al. JTCVS 2006

17 Goals for aortic valve repair Treat annular base and STJ dilated Ø Preserve root dynamics (neosinus of Valsalva) Preserve root expansibility (interleaflet triangles) Restore cusp effective height Cochran 1995 David III 1996 Van Son 1999 Thubrikar 2001 De Paulis Hopkins 2003 Demers 2004 Gleason 2005 Hess 2005 Maselli 2006 Kollar 2007 Hetzer 2008 Ruvuolo 2009 Sievers 2010 Need for standardization

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19 Standardization based on aortic annulus Ø Tube graft for remodelling = aortic annulus Ø Aortic annular base Ø (Hegar dilators, mm) Valsalva graft Ø (mm) Extra aortic ring Ø (mm) Subvalvular ring = down size from one size

20 24 surgeons - 14 centres 187 patients with Remodeling + External subvalvular aortic ring annuloplasty Eye Balling Alignment of cusp free edges Measurement of cusp effective height N Bicuspid 10 (13.5%) 11 (17.7%) 19 (37.3%) * Pre-op annulus Ø 28 (26 28) 26 (25 28) 28 (26 29) Cusp repair 15 (20.3%) 19 (30.6%) 36 (70.6%) * Ring Ø 28 (26 28) 28 (25 28) 27 (25 27) Residual AR 2 6 (8.1%) 8 (12.9%) 1 (1.9%) * Re-repair Conversion Post-op annulus Ø % (19 21) diameter, 20 (19 gradient 21) 5.2±2.320 mmhg (19 21) Op. mortality 2 (2.7%) 2 (3.2%) 2 (3.9%) Lansac. J Thorac Cardiovasc Surg 2010; 140: S28-35

21 Follow-up events 1 year follow up Latest follow-up AI 2 Reoperation Composite outcome Median FU AI 2 Reoperation Eye Balling 16 (25.0%) 2 (3.1%) 18 (28.1%) 54 (38-67) 17.6% (13) 1 endocarditis 8.1% Cusp (6) prolapse Alignment of cusp free edges 9 (15.0%) 1 (1.7%) 9 (15.0%) 24 (19-31) 14.5% (9) 1 endocarditis 4.8% Cusp (3) prolapse Measurement of cusp effective height 0 (0.0%) 0 (0.0%) 0 (0.0%) 10 (4-14) 0 0 Risk factors for AR recurrence «Eye Balling» Residual AR Tricuspid valve Lansac. J Thorac Cardiovasc Surg 2010; 140: S28-35

22 Phenotypes of the ascending aorta Aortic root aneurysm Supra-coronary aneurysm Isolated AI Valsalva 45 mm Valsalva<40 mm Valsalva<40 mm Supra coronary Aorta >45 mm Supra coronary Aorta < 40 mm Standardized and physiological approach to aortic valve repair Root reconstruction Remodeling + sub-valvular annuloplasty Supra-coronary graft + sub-valvular annuloplasty (annulus > 25 mm) Subvalvular annuloplasty Cusp repair + Resuspension of cusp effective height Subvalvular aortic annuloplasty

23 Post aortic valve repair TEE analysis What is a good result?

24 A good result Patient may expect at -10 years postop 85-95% survival 90-95% freedom from reoparation 80-90% freedom from moderate to severe AR Subramanian S. Herz 2010; 35 (2):88-93

25 A good result is related to A proper patient selection A standardized approach A good immediate result

26 TEE control Risk factor for reoperation Satisfactory results AR > grade I Eccentric jet Prolapsing cusps Tip of coaptation at the level of the aortic annulus or below AR grade I Tip of coaptation above the plane of aortic annulus Coaptation height > 5 mm

27 Decision to rerepair / replace Valvular factors Mechanism of residual AR Quality of valve tissue Aggressiveness of attempted repairs Patient factors Age Comorbidities LV function Choice of prosthesis

28 Correlates with Size of individuals Effective height Aortic root diameters 9 mm = excellent predictor for a good hemodynamic outcome (residual AR < 2) Bierbach BO. Eur J Cardiothorac Surg 2010; 38:

29 BAV: dilated AVJ 316 patients, 49 ± 14 years, 268 male, reconstruction of regurgitant BAV Hosp. Mortality 0.63% Survival 92% at 10 years Freedom from reoperation 88% at 5 years 81% at 10 years Freedom from aortic valve replacement 95% at 5 years 84% at 10 years Aicher D. Circulation 2011; 123:

30 BAV: dilated AVJ Aicher D. Circulation 2011; 123:

31 BAV: need for pericardial patch For raphe repair Aicher D. Circulation 2011; 123: Boodhwanni M. J Thorac Cardiovasc Surg 2010; 140:

32 BAV Circumferential orientation of the commissures determines outcome Aicher D. Circulation 2011; 123:

33 BAV: freedom from reoperation Aicher D. Circulation 2011; 123:

34 AV repair: effect of AR type 163 patients AV surgery, 117 males, 58 ± 14 years 125 valve repair or sparing 38 valve replacement Type 1: aortic dilatation Type 2: cusp prolapse Type 3: restrictive cusp motion or endocarditis le Polain de Waroux JB, Circulation 2007; 116: I 264

35 AV repair: effect of AR type le Polain de Waroux JB, Circulation 2007; 116: I 264

36 Death AR > grade 2 reoperation le Polain de Waroux JB, Circulation 2007; 116: I 264

37 Height of resuspension and early valve failure 101 patients aortic root reconstruction by reimplantation of the native valve 52 males, 49.1 ± 20.6 years Pethig K. Ann Thorac Surg 2002; 73: 29-33

38 Height of resuspension and early valve failure Pethig K. Ann Thorac Surg 2002; 73: 29-33

39 Mechanisms of Recurrent AR after Aortic Valve Repair Le Polain de Waroux JB. J Am Coll Cardiol 2009; 2:

40 Le Polain de Waroux JB. J Am Coll Cardiol 2009; 2:

41 No Residual AR Residual AR, coapt > 4mm Residual AR, coapt < 4mm Coaptation below annulus Le Polain de Waroux JB. J Am Coll Cardiol 2009; 2:

42 Risk of aortic repair failure Le Polain de Waroux JB. J Am Coll Cardiol 2009; 2:

43 What is a good result? A good coaptation High eh 9 mm Long 5 mm No residual or induced prolapse No residual AR A good valve opening

44 THANK YOU