Reimplantation Should Be Preferred
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1 Reconstruction of the Aortic Valve and Root: A Practical Approach September 13 th -15 th, 2017, Homburg/Saar, Germany Reimplantation Should Be Preferred Laurent de Kerchove, MD, PhD Cliniques Universitaires St-Luc, IREC, UCL, Brussels, Belgium
2 X X X X X X X X 1234
3 VSRR: At the beginning Of the Valve Sparing Root Replacement Era
4 VSRR: At the beginning Remodeling technique (1983) Reimplantation technique (1992) Sir M. Yacoub Prof. T. David
5 VSRR: Initial enthusiasm for both techniques (Reimpl Remod) Stanford Harrefield 1983 Toronto 1992 Hopkins Lubeck Hannover 1993 Brussels 1996 Kari F.A. Circ 2013
6 VSRR: Why so such hesitation? Remodeling Reimplantation Faster Less root dissection Only 1 suture line More hemostatic Annuloplasty
7 VSRR: Doubt on Remodeling Stanford Toronto 1992 Hopkins Harrefield Lubeck Hannover 1993 Brussels : 158 patients : 82 Marfans M.H. Yacoub JTCVS 1998 E.J. Birks. Circ 1999
8 VSRR: Doubt on Remodeling Stanford Toronto 1992 Hopkins Harrefield Lubeck Hannover 1993 Brussels : 220 patients : 61 Marfans T. David JTCVS 2006 N. de Oliveira JTCVS 2003
9 VSRR: Doubt on Remodeling Stanford Toronto 1992 Hopkins Harrefield Lubeck Hannover 1993 Brussels 1996 C. Miller ATS 2007
10 VSRR: Doubt on Remodeling N.D. Patel ATS 2008 Stanford Toronto 1992 Hopkins Lubeck Harrefield Hannover 1993 Brussels 1996 S.M. Cattaneo
11 VSRR: Doubt on Remodeling Toronto Hopkins Stanford 2001 Lubeck Harrefield Hannover 1993 Brussels R.G. Leyh
12 VSRR: Doubt on Remodeling Toronto Hopkins Stanford 2001 Lubeck Harrefield Hannover 1993 Brussels Remodeling A.W. Erasmi ATS2007
13 VSRR: Lack of annuloplasty in Remodeling Toronto Hopkins Stanford 2001 Lubeck Harrefield Hannover 1993 Brussels 2001 Hanke T., Sievers H.J. JTCS 2009: 191 VSRR, 76% TAV 56% Remodeling
14 VSRR: While the world was almost bleu and in peace Paris Homburg 1995 Two irreducible Gallic....
15 VSRR: The rational for Remodeling? Paris Homburg 1995 R.G. Leyh Circ A. Erasmi JTCVS 2005 Snapshot, close to native AV dynamics does not mean DURABILITY! LACK of annuloplasty in remodeling seems influence much more durability!
16 VSRR: Lack of annuloplasty in Remodeling Homburg Kunihara T., Schäfers H.J. JTCVS VSRR, 70% TAV, 93% Remodeling
17 % % Navarra E. EJCTS 2013 De Kerchove L. EJCTS VSRR: Annuloplasty in Reimplantation 60 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 TAV p=0.38 VAJ <28mm VSR VAJ 28mm VAJ 28mm VSR VAJ 28mm FF AR >1+ p = 0.4
18 VSRR: Longest term results of Reimplantation vs Remodeling Toronto : 371 patients (296 Reimpl 75 Remod) T. David JTCVS 2014
19 VSRR: Longest term results of Reimplantation vs Remodeling.. Hopkins.... Toronto : 146 Marfans (121 Reimpl 25 Remod) : 146 Marfans (69 Reimpl 29 Remod) T. David JACC 2015 J. Price JTCVS 2016
20 VSRR: Evolution of the Remodeling technique Reimplantation Circumferential external band Suture Annuloplasty But Operative time! Root dissection! AV dynamics? Bleeding? Improve durability? E. Lansac 2006 (started in 2003) H.J. Schäfers 2013 (started 2008)
21 VSRR: Doubt on the Reimplantation technique Bissell M. Eur Heart J Katayama JTCVS 2008 Reimplantation Risk of cusp damage and rapid deterioration of the valve! Only very occasionally reported No significant clinical impact R.G. Leyh Circ Max valve opening coronary vascularisation Stress less opening/closure
22 VSRR: Evolution of the Reimplantation technique Reimplantation David V Stanford Modification Valsalva Sinus Graft Cardioroot C. Miller R. De Paulis 2002 Sinus Graft H. Sievers
23 VSRR: Why Reimplantation should be preferred Safe and reproducible, disseminated worldwide Proven durability up to 15y in TAV, BAV, Marfan and dissection! One sizing, one device (graft) ( Remodeling + annuloplasty) Costs of the procedure! Ability to modify valve geometry (from asymmetric BAV to 180 symmetric configuration) ( Remodeling ± annuloplasty)
24 VSRR: Wathever the technique you choose, do a Reimplantation! Brussels Gallic s Technique Homburg Gallic s technique Paris Gallic s technique
25 Thank you Me at diner tonight!
26 VSRR: Why Reimplantation should be preferred But, excellent long term durability can be achieve in Reimplantation only if Technical pitfalls avoided (sizing, commissure resuspension) Appropriate cusp management Central Cusp Plication Schäfers HJ. JTCVS 2006 Aicher D. Circ. 2011
27 VSRR: How to do it? Central Cusp Plication Schäfers HJ. JTCVS /2 El Khoury G. Aicher D. Circ. 2011
28 VSRR: How to do it? Cusp Repair! Pethig K. ATS 2002 Tips > annulus, No AR Residual AR, Coapt >4 mm Cusp Repair! Tips > annulus Residual AR Coapt < 4 mm Tips < annulus le Polain JB. JACC Card. Im. 2009
29 VSRR: How to do it? Rate of cusp repair in VSRR TAV El Khoury 53% Reimplantation David 60% mixte Schäfers 90% Remodeling BAV El Khoury 95% Reimplantation Schäfers 95% Remodeling Miller 66% Reimplantation AR 0-1+ AR 2+ AR cusp 2 cusps 3 cusps 0 RCC LCC NCC
30 VSRR: How to do it? Brussels Technique 1. Valve inspection 2. Root dissection 3. Complex cusp repair 4. Graft sizing & proximal suture line 5. Com. reimplantation & distal suture line 6. Residual prolapse repair 7. Coronary reimplantation
31 VSRR: How to do it? Brussels Technique 1. Valve inspection 2. Root dissection 3. Complex cusp repair 4. Graft sizing & proximal suture line 5. Com. reimplantation & distal suture line 6. Residual prolapse repair 7. Coronary reimplantation
32 VSRR: How to do it? Brussels Technique 1. Valve inspection 2. Root dissection 3. Complex cusp repair 4. Graft sizing & proximal suture line 5. Com. reimplantation & distal suture line 6. Residual prolapse repair 7. Coronary reimplantation
33 VSRR: How to do it? 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
34 VSRR: How to do it? Brussels Technique 1. Valve inspection 2. Root dissection 3. Complex cusp repair 4. Graft sizing & proximal suture line 5. Com. attachment & distal suture line 6. Residual prolapse repair 7. Coronary reimplantation
35 VSRR: How to do it? Brussels Technique 1. Valve inspection 2. Root dissection 3. Complex cusp repair 4. Graft sizing & proximal suture line 5. Com. reimplantation & distal suture line 6. Residual prolapse repair 7. Coronary reimplantation
36 VSRR: How to do it? Brussels Technique Post-repair TEE
37 VSRR: Why and How to do it? Conclusions VSRR is SAFE, DURABLE, EXC. LT. SURVIVAL & FEW VRE (< Bentall) in TAV, BAV but also Marfan and AAD with Reimplantation and with Remodeling techniques Condicio sine qua non ANNULOPLASTY & CUSP REPAIR!
38 VSRR: The Litterature Remodeling Reimplantation Birks EJ., Yacoub MH. Circulation De Olievera NC., David TE. JTCVS 2003 Miller DG. JTCVS 2003 Bethea BT., Cameron D. ATS 2004 David T. JTCVS 2006 Erasmi A., Sievers HH. ATS 2007 Suggest better repair durability with the Reimplantation technique
39 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
40 Valve sparing root replacement Remodeling Reimplantation a = STJ a = graft size b c Prolapse level? b c
41 VSRR: Why to do it? Hospital mortality 12% AAD 1% (4/371 pts Reimpl. & Remod.) T. David JTCVS % AAD 2% (6/747 pts Remodeling) H-J Schäfers EJCTS % AAD 2% (4777 pts Metanalysis) B. Arabkhani ATS 2015 Elective 0.3% (1/381 pts Reimplantation) G. El khoury, updated series % AAD 0.7% (1/146 Marfan Reimpl. & remod.) T.David JACC % AAD 0% (0/98 Marfan Reimpl. & remod.) J. Price JTCVS SAFE!
42 VSRR: Why to do it? Freedom from Reoperation Reimpl. & Remod. Remodeling Reimplantation Overall 18 y Overall 91%@ 15 y Overall 95%@ 12 y T. David JTCVS 2014 H-J Schafers EJCTS Durable! S. Mastrobuoni STSA 2014
43 VSRR: Why to do it rather than Bentall? VSRR Bentall 3. Exc. LT. Survival! 4. Few VRE! B. Arabkhani, JJ. Takkenberg ATS 2015 A. Mookhoek, JJ. Takkenberg ATS 2016
44 VSRR: How to do it? David Operations Kari F.A. Circ 2013
45 VSRR: How to do it? Brussels Way Graft Sizing: N/L com height method = STJ
46 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
47 VSRR: How to do it? Remodeling Reimplantation Birks EJ., Yacoub MH. Circulation De Olievera NC., David TE. JTCVS 2003 Miller DG. JTCVS 2003 Bethea BT., Cameron D. ATS 2004 David T. JTCVS 2006 Erasmi A., Sievers HH. ATS 2007 Suggest better repair durability with the Reimplantation technique
48 Predictors of AR recurrence Coaptation height Bierbach B.O. EJTCS 2010 Aicher D. Circulation ;123:178-85, 2011
49 AV repair: Probability of Cusp Repair in valve sparing surgery No AR low 10 % AR, central jet Moderate % AR, eccentric jet High 100 %
50 Effect of VAJ size on AV repair durability Kunihara T., Schäfers H.J. JTCS 2012: 430 VSRR, 70% TAV, 93% remodeling
51 VSRR: How to do it? Hanke T. JTCVS 2009 Kunihara T. JTCVS 2012
52 VSRR: Outcomes of historical cohort : 158 patients : 371 patients (296 Reimpl 75 Remod.) Sir M. Yacoub T. David T. David JTCVS : 146 Marfans (121 Reimpl 25 Remod.) : 82 Marfans M.H. Yacoub JTCVS 1998 E.J. Birks. Circ 1999 T. David JTCVS 2014 T. David JACC 2016
53 VSRR: Why to do it in Marfan syndrome? Survival Freedom from TE/Bleeding event Freedom from Reoperation VSRR 10 y Bentall 10 y J. Price JTCVS 2016
54 VSRR: Why to do it in Marfan syndrome? Freedom from Reoperation Freedom from AI >2+ 5% 15 y Overall 15 y T. David JACC 2015
55 VSRR: Remodeling+annuloplasty long term result Lansac E., EJCTS 2006: 87 pts, 95% TAV 100% Remodeling, 60% with ring annuloplasty Less early residual or recurrent AI in Remodeling + ring group Aicher D., JTCS 20013: 559 BAV repair 193 (34%) VAJ suture annuloplasty in patient VAJ >27 mm Less early residual or recurrent AI in annuloplasty group
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