Aortic Valve Repair: The Brussels Approach Laurent de Kerchove, MD, PhD Cliniques Universitaires St-Luc, IREC, UCL, Brussels, Belgium
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1 Reconstruction of the Aortic Valve and Root: A Practical Approach September 14 th -16 th, Homburg/Saar, Germany Aortic Valve Repair: The Brussels Approach Laurent de Kerchove, MD, PhD Cliniques Universitaires St-Luc, IREC, UCL, Brussels, Belgium
2 AV repair program in Brussels : 850 Aortic valve repair/sparing
3 Pathologies amenable to AV repair Congenital - Bicuspid - Connective tissue disorders (Marfan, Loeys-Dietz, Ehler- Danlos, Familial Aneurysmal disease, ) - Unicuspid - Quadricuspid - Supra-aortic stenosis
4 Pathologies amenable to AV repair Acquired - Degenerative cusp - Degenerative aortic aneurysm (Atherosclerosis) - Traumatic - Infectious - Acute aortic dissection
5 Pathologies amenable to AV repair Redo - Ross repair - Re-repair
6 Functional classification of AI Lesson from the mitral valve Etiology MV FED AV Marfan Lesion Cordale rupture Root dilatation Dysfunction Prolapse eccentric MI Cusp tethering central AI
7 Functional classification of AI Lesson from the mitral valve Common language Plan surgical strategy Predict the outcomes Type I Annulus dilatation Type II Leaflet prolapse Type III a,b Leaflet restrictive motion A. Carpentier
8 Functional classification of AI The Functional Aortic Valve Unit 2. STJ 1. Cusp FAA 3. VAJ
9 Functional classification of AI El Khoury G. Cur. Op. Card. 2005
10 Functional classification of AI Type 1: FAA Dilatation Type 1a Asc. Ao. (STJ) Type 1b Root (STJ +VAJ) Type 1c VAJ 31 mm
11 Functional classification of AI Type 1a and 1b: STJ dilatation Functional restriction of the cusp (tethering) central AI Effective height = supra normal (>9-10mm) Free margin elongation Commissural fenestration
12 Functional classification of AI Normal VAJ Type 1b and 1C: VAJ dilatation Effective height = infra normal (<9-10mm) Frequently associated with cusp prolapse Dilated VAJ
13 Functional classification of AI Type 2: Prolapse Eccentric jet Cusp billowing Transverse fold in cusp curvature M. Boodhwani, JTCVS 2013
14 Functional classification of AI Type 2: Prolapse Transverse fold in cusp curvature = Free margin elongation below other normal FM Commissural fenestration
15 Functional classification of AI Type 3: Restrictive cusp motion
16 Functional classification of AI Type 3: Restrictive cusp motion
17 Functional classification of AI Type 1d: Cusp perforation/destruction (no prolapse, no restriction)
18 Functional classification of AI Type 1b+2 Type 1c+2
19 Principles of AV repair 1. Restore and preserve cusp geometry and motion + 2. Remodel and stabilize the FAA Optimal area of coaptation, stable over time
20 Principles of AV repair: Optimal coaptation Tips > annulus, No AR Residual AR, Coapt L >4 mm Tips > annulus, Residual AR, Coapt L <4 mm Tips < annulus Pethig K. ATS 2002 le Polain JB. JACC Card. Im. 2009
21 Principles of AV repair: Optimal coaptation Schafers H.J. JCTVS 2006 Bierbach B.O., EJCTS 2010 Aicher D. Circ. 2011
22 Techniques of cusp repair Cusp lesions Prolapse (type 2) - Free margin elongation - Fenestration - Commissure disruption Restriction/retraction (type 3) - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction (type 1d) Repair techniques Central plication or Goretex resuspension Goretex resuspension or Patch Commissure reattaching or Patch Resection + direct closure or patch Resection + Patch Resection + Patch Patch
23 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation - Fenestration - Commissure disruption Restriction/retraction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction Repair techniques Central plication
24 Central Plication Technique: 1 cusp prolapse
25 Central Plication Technique: 1 cusp prolapse
26 Central Plication Technique: 1 cusp prolapse
27 Central Plication Technique: 1 cusp prolapse
28 Central Plication Technique: 1 cusp prolapse
29 Central Plication Technique: 1 cusp prolapse
30 Central Plication Technique: 1 cusp prolapse
31 Central Plication Technique: 3 cusps prolapse 9-10 mm eh 1/2 1/2 LCC NCC
32 Central Plication Technique: 3 cusps prolapse 9-10 mm eh 1/2 1/2 LCC NCC
33 Central Plication Technique: 3 cusps prolapse 9-10 mm eh 1/2 1/2 LCC NCC
34 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation - Fenestration - Commissure disruption Restriction/retraction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction Repair techniques Central plication
35 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation - Fenestration «small» - Commissure disruption Restriction/retraction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction Repair techniques Central plication + Gtx Resuspension
36 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation - Fenestration «large» - Commissure disruption Restriction/retraction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction Repair techniques Patch repair (2 patches) + Gtx resuspension
37 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation - Fenestration «rutpured» - Commissure disruption Restriction/retraction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction Repair techniques Patch repair (butterfly techn.) + Central Plication
38 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation - Fenestration - Commissure disruption Restriction/retraction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction Repair techniques Comm. reattachment + Goretex resuspension
39 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation - Fenestration - Commissure disruption Restriction/retraction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction Repair techniques Resection direct closure + VS Reimplantation
40 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation - Fenestration - Commissure disruption Restriction/retraction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction Repair techniques Resection + Patch repair
41 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation - Fenestration - Commissure disruption Restriction/retraction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction Repair techniques Resection + Patch repair
42 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation - Fenestration - Commissure disruption Restriction/retraction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction Repair techniques Cusp extension with patch
43 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation Repair techniques Patch repair - Fenestration (large/rutpured) - Commissure disruption Restriction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/Destruction
44 Techniques of cusp repair: Outcome following type of AI All repair cohort Freedom from AR >2+ BAV repair Freedom from AR >2+ P=0.03 P=0.02 M. Boodhwani, JTCVS 2009 Boodhwani M. JTCVS 2010
45 Techniques of FAA repair Aorta lesions Repair techniques Type 1a: Asc Ao (STJ) Supra coronary ascending aorta replacement Type 1b: Root (STJ + VAJ) Valve Sparing Reimplantation Type 1c: VAJ Subcommissural annuloplasty or Ring annuloplasty
46 Techniques of FAA repair Aorta lesions Repair techniques Type 1a: Asc Ao (STJ) Supra coronary ascending aorta replacement Type 1b: Root (STJ + VAJ) Type 1c: VAJ
47 Techniques of FAA repair Aorta lesions Repair techniques Type 1a: Asc Ao (STJ) Valve Sparing Reimplantation Type 1b: Root (STJ + VAJ) Type 1c: VAJ
48 VS Reimplantation: Brussels Technique 1. Valve inspection STJ 2. Root dissection 3. Complex cusp repair L/R R/N N/L 4. Graft sizing & proximal suture line 5. Com. reimplantation & distal suture line 6. Residual prolapse repair L/R R/N N/L 7. Coronary reimplantation
49 Techniques of FAA repair Aorta lesions Repair techniques Type 1a: Asc Ao dilat (STJ) Subcommissural annuloplasty or Ring annuloplasty Type 1b: Root (STJ + VAJ) Type 1c: VAJ
50 Techniques of FAA repair Ring annuloplasty
51 Techniques of FAA repair TAV BAV SCA: Root < 45 mm VSR: Root > 45 mm
52 % % Techniques of FAA repair Subcommissural annuloplasty and VAJ size BAV TAV FF FF AR AR >1+ > VAJ <30mm VAJ 30mm A A p < 0.01 Navarra E. EJCTS 2013 FF AR >1+ SCA VAJ 28mm SCA VAJ VAJ <28mm 28mm SCA VAJ VAJ 28mm 28mm SCA VAJ 28mm p= p= De Kerchove L. EJCTS 2015
53 Techniques of FAA repair SCA and VAJ size Preop TEE Postop TEE VAJ dilatation Pre-redo TEE 29 mm 24 mm 29 mm 30 y : BAV, rapher res+direct closure, cusps resusp (Gtx), SCA 6.5 y later: AI 3+ Preop TEE Postop TEE Pre-redo TEE 31 mm 22 mm 31 mm 41 y : TAV, RC plication and resuspension (Gtx), SCA 2 y later : AI 3+
54 % % Techniques of FAA repair VS Reimplantation and VAJ size SCA VAJ 28mm SCA VAJ 28mm p= BAV Pts at risk Years VAJ VAJ > FF AR > VAJ <30mm 80 VAJ 30mm B p = 0.93 Navarra E. EJCTS 2013 TAV p=0.38 VAJ <28mm VSR VAJ 28mm VAJ 28mm VSR VAJ 28mm FF AR >1+ p = 0.4 De Kerchove L. EJCTS 2015
55 Techniques of FAA repair SCA and VAJ size p=ns p<0.001 De Kerchove L. EJCTS 2015
56 Brussels annuloplasty strategy (AV repair for severe AI) Normal Root (<40 mm) Dilated Root ( 40 mm) Normal VAJ (<28 mm) «Old patient» (>50 y) Large VAJ ( 28 mm) Large VAJ ( 28 mm) Root wall fragility Remodel BAV geometry 180 Subcom. annuloplasty External Ring Annuloplasty VS Reimplantion
57 Thank you
58 Main goal of AV repair: Optimal coaptation + Stabilisation Effective height (eh) 9 mm Coaptation length 4 mm Circumferential annuloplasty VAJ 28 No residual AI Good cusp mobility Pethig K. ATS 2002 le Polain de Waroux JB. JACC Card. Im Bierbach BO. EJCTS 2010 Aicher D. Circ De Kerchove L. JTCVS 2011
59 Brussels AV repair: Conclusions The mechanisms of AI are actually well understood and the use of a classification help to discuss indication, plan surgical strategy and analyze the outcomes. 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 in Type 1 (FAA dilatation) and 2 (Prolapse) and acceptable in type 3 (Restrictive). Next to leaflet tissues quality, optimal valve coaptation and annuloplasty are the principal determinants of repair durability.
60 AV Repair: Hospital Mortality (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: 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
63 AV Repair: Valve sparing in Marfan Syndrome Freedom from AV reoperation Freedom from AR >2+ T. David, JTCVS 2009
64 AV Repair: Leaflet repair in valve sparing surgery H.J. Schäfers ATS 2002 L. de Kerchove Circ Cusp repair = risk factor of reoperation or recurrent AR E. Lansac EJCTS 2010 (negative impact of cusp repair decrease with experience) P.P. Urbanski EJCTS 2012
65 AV repair Risk factor of repair failure: Cusp coaptation Tips > annulus, No AR Residual AR, Coapt >4 mm Tips > annulus Residual AR Coapt < 4 mm Pethig K. ATS 2002 Tips < annulus le Polain JB. JACC Card. Im Aicher D. Circ. 2011
66 AV repair Risk factor of repair failure: VAJ dilatation No annuloplasty SC annuloplasty Aicher D. Circ Navarra E. EJCTS 2013
67 AV repair 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
68 AV repair Valve sparing reimplanation in BAV repair % 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
69 AV repair Aorta/Annuloplasty repair strategy AV repair for AR Normal Root (<45 mm) Dilated Root ( 45 mm) Normal VAJ (<26 mm) Large VAJ (>26 mm) Large VAJ (>26 mm) + Modify valve geometry Subcom. Anpl. Ring Annuloplasty VS Reimplantation
70 AV repair Risk factor of repair failure: Patch repair Boodhwani M. JTCVS 2010 Aicher D. Circ. 2011
71 AV repair: Probability of Cusp Repair in valve sparing surgery No AR low 10 % AR, central jet Moderate % AR, eccentric jet High 100 %
72 AV Repair: Valve related event Thromboembolic event 0.2 % - 0.7% /y 10 y; 15 y Endocarditis 0.2% /y All VRE (reop, thromb, bleed, endoc) 10 y; 18 y V. Sharma, H. Schaff JTCVS 2014 J. Price, G. Elkhoury ATS 2013 D. Aicher, H-J Schafers EJCTS 2010 T. David JTCVS 2014
73 AV Repair: Prolapse repair (Type 2) 93% 93% 87% M. Boodhwani, JTCVS 2011
74 AV Repair: Leaflet repair with patch Mozala Nezhad Z. EJCTS 2014
75 BAV Repair Cusp Anatomy Type 0 Type 1 Prolapsing Raphe Morphology Restrictive Raphe Thinned Raphe Resected Quantity of Cusp Tissue? Adequate Inadequate Central Plication, Triangular Resection Tricuspidisation 180 Triangular Patch 120 Commissural Patch
76 AV Leaflet Repair: Results Unicuspid valve repair : 118 pts mean age: 27 years FF 3 years: 80% 86 % Design I Design II D. Aicher JTCVS 2013
77 Functional classification of aortic regurgitation Mechanism of AV dysfunction Padial LR, Am Heart J Keane MG, Circulation In patients with chronic AR, the severity of AR is correlated with the degree of STJ and VAJ dilatation
78 Functional classification of aortic regurgitation Mechanism of AV dysfunction Type I characteristics Central jet to subvalvular plane all cusps have same coaptatin hight lack of central coaptation
79 Principles of AV repair/sparing surgery Optimal coaptation?
80 Central Plication Technique: 2 cusp prolapse
81 Central Plication Technique: 2 cusp prolapse repair
82 Central Plication Technique: 2 cusp prolapse
83 Central Plication Technique: 2 cusp prolapse
84 Central Plication Technique: 2 cusp prolapse
85 Central Plication Technique: 2 cusp prolapse
86 Central Plication Technique: 2 cusp prolapse
87 Central Plication Technique: 2 cusp prolapse
88 Central Plication Technique: 2 cusp prolapse
89 Central Plication Technique: 2 cusp prolapse
90 Reimplantation Technique Probability of Cusp Repair AV morphology In tricuspid 52% T. David JTCS. 2006: ±58% D. Aicher. JTCS 2007: ±53% In bicuspid 93% D. Aicher. JTCS 2007: ±86%
91 Reimplantation Technique Probability of Cusp Repair Preoperative AR In tricuspid 52% D. Aicher. JTCS 2007 E. Lansac EJCTS AR 0-1+ AR 2+ AR 3+
92 Reimplantation Technique Probability of Cusp Repair cusp 2 cusps 3 cusps 0 RCC LCC NCC
93 Reimplantation Technique Probability of cusp repair AV Preoperative Operarive morphology period AR In tricuspid 52% AR 0-1+ AR 2+ AR 3+ In bicuspid 93% D. Aicher. JTCS 2007 E. Lansac EJCTS AR 0-1+ AR 2+ AR
94 Reimplantation Technique Probability of cusp repair Preoperative AR 0-1+ In tricuspid
95 Reimplantation Technique Water Test, residual prolapse repair
96 AV Repair Surgery for AI Symptomatic severe AI Assympt severe AI + EF <50% or + LVED >65 (70) mm, LVES >50 mm Surgery for Ao. Aneurism > 55 mm in TAV > 50 mm in Marfan, BAV at risk > 45 mm in Marfan at risk, if surgery for severe AI
97 2. Patients selection for AV repair 1. Pediatric 2. Young adults 3. > 65 years Main TARGET of AV repair = 23% of AV repair population ( , 620 pts) 1-2%/y
98 BAV Repair Classification of cusp phenotypes << >>> H. Sievers, J.Thor. Cardiovasc.Surg. 2007
99 Techniques of cusp repair Cusp lesions Prolapse - Free margin elongation - Fenestration «large» - Commissure disruption Restriction - Raphe in BAV - Unicuspid valve - Fibosis/Calcification Perforation/destruction Repair techniques Patch repair (2 patches)
100 BAV repair Classification of cusp phenotypes Type 0 (Sievers Classif.) Type 1 (Sievers classif.) 180 No raphe Prolapse Raphe Complete fusion Prolapse Thick, calc. raphe Incomplete fusion Restrictive
101 BAV Repair Aortopathy Dilated Asc. Aorta Dilated Root Normal Aorta Dilated ventriculo-aortic junction mm de Kerchove JTCVS 2010 Schäfers JTCVS 2013
102 BAV repair Valve sparing Reimplantion 1. Circumferential prosthetic based annuloplasty 2. Modify commissure orientation ( 180 ) Improve durability Reduce the need of patch repair Type 1 BAV
103 % Techniques of FAA repair 20 SCA vs VSR (matched comparison) BAV Years Pts at risk VAJ FF AR >1+ VAJ > p= TAV FF AR >1+ B VSR VSR VAJ 28mm SCA VSR VAJ 28mm p = De Kerchove L. JTCS 2010 p=0.38 De Kerchove L. EJCTS 2015
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