Repair for Aortic Regurgitation: is it durable?
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1 Repair for Aortic Regurgitation: is it durable? Gébrine El Khoury Cliniques Universitaires St-Luc, IREC, UCL, Brussels, Belgium AATS 95 th Annual Meeting April, Seattle
2 Aorrtic valve repair the basics -role of the functional aortic annulus:faa dilation -role of the free margin of the leaflets:fm elongation
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6 Yacoub David
7 First «basic»: Aorrtic valve repair the basics Despite of normal leaflets, root aneurysms (FAA Dilation) may induce aortic regurgitation, and the restoration or recreation of normal root (FAA) corrects the regurgitation. Concept: LESION DYSFUNCTION TREAT THE LESION, CORRECT THE DYSFUNCTION
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9 Leaflet prolapse:excess length of free margin, shortening (plication) correct prolapse and AR
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11 Aorrtic valve repair the basics -Second «basic»: Leaflet prolapse: excess length of free margin shortening (plication) of the free margin correct prolapse and AR
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13 Aorrtic valve repair the basics -third «basic» -Close relationship betweec FAA and FM leaflet coaptation and MOTION -close relationship between FAA and AR FAA dilation AR
14 Understanding Valve Dysfunction Classification of Dysfunctions Echocardiographic Assessement Classification Surgical Assessement STJ Sino-tubular Junction; SCA Sub-Commissural Annuloplasty Dysfunction etiology lesion repair JTCVS 2009;137:286-94
15 Functional classification of aortic regurgitation Mechanism of AV dysfunction Type 1 AR : FAA dilatation Type 1a (STJ) Type 1b (STJ+VAJ) Type 1c (VAJ)
16 AV repair for AI: Mechanisms of AI Cusp perforation (Type 1d)
17 AV repair for AI: Mechanisms of AI Cusp prolapse (Type 2)
18 AV repair for AI: Mechanisms of AI Restricted cusp motion (Type 3)
19 Fundamental Principles of Valve Repair - Preserve or restore normal motion Leaflets - Create a large surface of coaptation - Remodel and stabilize the annulus Close functional relationship (functional unit)
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21 Valve repair and durability Determinants of durabilty: Quality &quantity of tissue, patient selection Appropriate surgical technique - Excellent immediate result of repair Leaflet coaptation,motion FAA stabilisation Long term durability
22 AV repair for AI: Determinant of durability A. Quality & quantity of tissue, patient selection B. Appropriate surgical technique
23 AV repair for AI: Etiology Congenital - Moncuspid - Bicuspid - Quadricuspid - Connective tissue disorders (Marfan, Loeys-Dietz, Ehler- Danlos, Familial Aneurysmal disease, )
24 AV repair for AI: Etiology Acquired - Degenerative cusp - Degenerative aortic aneurysm (Atherosclerosis) - Traumatic - Infectious - Acute aortic dissection
25 AV repair for AI: Etiology Redo - Ross repair - Re-repair
26 Valve repair and durability Determinants of durabilty: Quality &quantity of tissue, patient selection Appropriate surgical technique - Excellent immediate result of repair Leaflet coaptation,motion FAA stabilisation Long term durability
27 AV repair for AI: Actual requirement Optimal coaptation + Stabilisation Effective height (eh) 9 mm Coaptation length 4 mm Circumferential annuloplasty VAJ >26 mm No residual AR Pethig K. ATS 2002 le Polain de Waroux JB. JACC Card. Im Bierbach BO. EJCTS 2010 Aicher D. Circ De Kerchove L. JTCVS 2011
28 AV repair for AI: Determinant of durability A. Quality & quantity of tissue, patient selection B. Appropriate surgical technique
29 AV repair for AI: Mecanisms of AI El Khoury G. Cur. Op. Card. 2005
30 Supracoronary Ascending Aortic Aneurysms (Type 1A)
31 Freedom from AV Reoperation Freedom from AV Reoperation Months No. at risk
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33 AV repair for AI: Root dilatation (Type 1b) - VSRR Toronto: , 371 pts, 9% BAV, 50% cusp repair 97% 93% 95% Freedom from Reop 95% 91% Freedom from AR 2+ 78% No predictors of recurrent AR T. David JTCVS 2014
34 AV repair for AI: Root dilatation (Type 1b) - VSRR Homburg: , 430 pts, 30% BAV, 73% cusp repair Freedom from AV reop. Freedom from AR 2+ T. Kunihara JTCVS 2012
35 AV repair for AI: Root dilatation (Type 1b) - VSRR Brussels: , 275 pts, 43% BAV, 70% cusp repair 100% 92% S. Mastrobuoni STSA 61 st meeting 2014
36 AV repair for AI: Root dilatation (Type 1b) in Marfan syndrome Toronto: , 103 pts, mean age 37 y Freedom from AV reoperation Freedom from AR >2+ T. David, JTCVS 2009
37 vssr+cusp repair
38 AV Repair for AI: VSRR +/- Cusp repair H.J. Schäfers Ann Thor Surg 2002 L. de Kerchove Circulation 2009
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40 AV Repair for AI: Results Prolapse repair (Type 2) 93% 93% 87% M. Boodhwani, JTCVS 2011
41 Tricuspidisation and 3 cusps extension
42 AV repair for AI: Isolated AI Cusp prolapse/restriction/perforation (Type 2,3, 1d) Mayo: , 331 pts, 40% BAV, 100% cusp repair 79% 72% 75% 58% Risk factors of reop: Severe preop AR, > mild AR at discharge Sharma V. JTCVS 2014
43 AV repair for AI: Predictor of recurrent AI Cusp restriction (Type 3) Freedom from AV reoperation Freedom from AR >2+ (Prolapse) (Restriction) (Prolapse) (Restriction) M. Boodhwani, JTCVS 2009 Cusp Height to define cusp restriction TAV < 16 mm BAV < 19 mm Schafers H.J. JTCVS 2013
44 AV repair for AI: Predictor of recurrent AI Cusp extension/restoration with Patch Boodhwani M. JTCVS 2010 Aicher D. Circ. 2011
45 AV Leaflet Repair: Results Leaflet repair with patch Mozala Nezhad Z. EJCTS 2014
46 Valve repair and durability Determinants of durabilty: Quality &quantity of tissue, patient selection Appropriate surgical technique - Excellent immediate result of repair Leaflet coaptation,motion FAA stabilisation Long term durability
47 AV repair for AI: Predictor of recurrent AI Coaptation length and height Tips > annulus, No AR Residual AR, Coapt >4 mm Tips > annulus Residual AR Coapt < 4 mm Tips < annulus le Polain JB. JACC Card. Im. 2009
48 AV repair for AI: Predictor of recurrent AI Coaptation length and height Aicher D. Circ. 2011
49 Valve repair and durability Determinants of durabilty: Quality &quantity of tissue, patient selection Appropriate surgical technique - Excellent immediate result of repair Leaflet coaptation,motion FAA stabilisation Long term durability
50 AV repair for AI: Predictor of recurrent AI Large ventriculo-aortic junction BAV repair No circumferential annuloplasty Remodeling Aicher D. Circ T. Kunihara JTCVS 2012
51 AV repair for AI: Predictor of recurrent AI Large ventriculo-aortic junction Non-circumferential Subcommis. Annuloplasty (Cabrol stitch) BAV repair TAV repair Navarra E. EJCTS 2013 de Kerchove EJCTS 2015
52 AV repair for AI: Predictor of recurrent AI Large ventriculo-aortic Years junction Pts at risk VAJ VAJ > Circumferential annuloplasty in VS Reimplantion B % p=0.38 VSR VAJ 28mm VSR VAJ 28mm Pts at risk Years VAJ VAJ > De Kerchove L. EJCTS 2015
53 AV repair for AI: Predictor of recurrent AI Large ventriculo-aortic junction Matched comparison VSR vs SCA p= % Freedom from AR>1+ Group SCA 1 Group VSR 2 6 years 64±15% 95±5% Months No. at risk Group Group De Kerchove L. JTCVS 2011
54 AV Leaflet Repair: Conclusions The mechanism of AR are actually well understood and the use of a classification of AR help to plan AV repair. Surgeon dispose of a wide armamentarium of repair techniques adapted to the variety of valvular lesions. Durability of leaflet repair depend on the quality and quantity of tissues; long term results are excellent for prolapse repair and acceptable for repair of restrictive lesion. Next to leaflet tissues quality, optimal valve coaptation and annuloplasty are other determinants of repair durability. Still, longer follow-up is necessary to investigate 2 decade after aortic valve repair.
55 AV repair for AI: Conclusions Is it durable? Yes Respect determinants of durabilty: Quality & quantity of tissue, patient selection Type 3 (calcif., short geom. height), patch repair Appropriate surgical techniques Optimal cusp coaptation, motion FAA stabilisation
56 Thank you
57 AV repair for AI: Patient demographic Mean age of patient with isolated AI: - 57 y Roberts WC. Circulation ± 14 y Sharma V. JTCVS y (TAV) vs 40 y (BAV) De Meester C. AHA 2012 Mean age of patient with aortic aneurism ± AI - 47 ± 15 y T. David JTCVS ± 15 y T. Kunihara JTCVS ± 11 y (BAV) F.A. Kari ICVTS 2014
58 Bioprosthesis durability in pts < 60 y Johnston D.R. Ann Thor Surg 2015 Bourguignon T. ATS % of 15 y
59 Bioprosthesis durability in pts < 60 y 50 y 55 y 60 y Bourguignon T. Ann Thor Surg 2015 Johnston DR. ATS 2015 > 25 % y for patient < 50 y
60 AV repair for AI: Hospital mortality in elective surgery 0.6% V. Sharma, H. Schaff JTCVS % J. Price, G. Elkhoury ATS % D. Aicher, H-J Schafers EJCTS % T. David JTCVS 2014
61 AV Repair: Long term Survival 81% V. Sharma, H. Schaff JTCVS % 81% 73% 90% 80% 77% J. Price ATS 2013 T. David JTCVS 2014
62 AV repair for AI: Patients Mean age of patient with severe AI: 50 ± 17 year - Tricuspid 59 ± 14 year - Bicuspid 40 ± 13 year De Meester C. AHA 2012 Johnston DR. ATS 2015 Bourguignon T. ATS 2015
63 Bioprosthesis durability in pts < 60 y Johnston DR. ATS 2015
64 Bioprosthesis durability in pts < 60 y Bourguignon T. Ann Thor Surg 2015
65 Bioprosthesis durability in pts < 60 y Johnston D.R. Ann Thor Surg % reoperation for 15 y
66 AV repair for AI: Root dilatation (Type 1b) Homburg: , 430 pts, 30% BAV, 73% cusp repair Freedom from AR 2+ T. Kunihara JTCVS 2012
67 AV Leaflet Repair: Results Long term outcomes ( : 475 pts, 68% leaflet repair) 84% 86% J. Price ATS 2013
68 AV Repair: Freedom from Reoperation & AI Authors Period Cohort Technique H. Schaff JTCVS Cusp 100% Sparing 0% FF AV Reop FF recurrent AR >2+ 10 y 80% 10 y 75% T. Kunihara JTCVS Cusp 80% Sparing 50% 10 y 88% 10 y 80% J. Price ATS Cusp 68% Sparing 50% 10 y 86% 10 y 85% T. David JTCVS Cusp 50% Sparing 100% 10 y 97% 18 y 95% 10 y 93% 18 y 78% Root pathology > Cusp pathology
69 AV repair for AI: TAV versus BAV Freedom from reoperation BAV 84% (7 y) Casselman JTCVS % (10 y) Aicher EJCTS % (10 y) Price ATS 2013 < TAV 94% (12 y) David JTCVS % (10 y) Aicher EJCTS % (10 y) Price ATS 2013
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