Reconstruction of the Aortic Valve and Root A Practical approach Failures after aortic valve repair. Diana Aicher. September 16 th -18 th 2015
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1 Reconstruction of the Aortic Valve and Root A Practical approach Failures after aortic valve repair Diana Aicher September 16 th -18 th 2015
2 Classification of failures- root repair 51/810 acute/ intraoperative conversions n=1 failures chronic n=50 (1-184 months postoperatively)
3 Patient Cohort Observation period Patients characteristics Primary operation Re-operation 7/1998 to 5/2014 Age: 44 ± 16 years Sex: 43 male/8 female Root remodeling n=45 [45/ 781 =6%]; acute dissection n=1/62 Reimplantation n=6 [6/29= 21%], acute dissection n=3/7 Valve morphology: tricuspid n= 19 (37%) bicuspid n= 27 (53%) unicuspid n= 5 (10%) interval between initial aortic valve repair and reoperation: months ( mean: 44 ± 50 months)
4 Causes for chronic failure after root repair (n=50) endocarditis n=6 secondary stenosis n=6 (bicuspid n=4; tricuspid n=2) Secondary cusp retraction n=4 VSD n=2 recurrent regurgitation n=32 Cusp prolapse n=19 rupture of a Trusler suture n= 2 recurrent dissection n=1 annular dilatation n=3 retraction/aortitis n=1 suture dehiscence after pericardial patch implantation n=4 suture dehiscence after triangular resection n=2
5 Hospital mortality 2/51 =4% Survival after Reoperation
6 Results of Reoperation Valve replacement (n=38/51 [75%]) Re-repair (n=13/51 [ 25%]) Ross-operation n=1 VSD closure n=2 mechanical valve replacement n=9 Valve-Re-Repair n=11 biological valve replacement n=28 Valve related complications: 2 pacemaker implantation (AV-block) 1 TIA (6 months postop.)
7 Reoperations n=13 recurrent regurgitation n=11 endocarditis n=2 Cusp prolapse n=6 Cusp perforation n=6 Insufficient commissural height n=5 Secondary cusp retraction n=4 Commissural dehiscence n=2 Inadequate valve configuration n=1 n=6 primarily operated in Homburg n=7 primarily operated in other hospitals Giebels et al. JTCVS 2013 /145(3):
8 Secondary cusp retraction L R N Intraoperative photograph of excised aortic cusps from a patient with Marfan syndrome 10 years after reimplantation Giebels et al. JTCVS 2013 /145(3):
9 Causes for chronic failure after cusp repair residual cusp prolapse cusp retraction unfavourable commissural orientation in a bicuspid aortic valve failed recognition of a unicuspid morphology suture dehiscence after pericardial patch implantation suture dehiscence after triangular resection
10 Solutions Effective height as indicator for cusp prolapse Schäfers et al ATS 2007:83:S740-5
11 Solutions Geometrical height (gh) Schäfers et al. JTCVS (2):269-74
12 Solutions Mean geometrical height: Bicuspid 24 ± 2mm Tricuspid 21 ± 3mm gh as indicator for cusp retraction Schäfers et al. JTCVS (2):269-74
13 Solutions Commissural orientation before and after root remodeling Schäfers et al. JTCVS ;S36-40
14 Management of failures replacement or re-repair? Retraction/stenosis replacement residual prolapse additional shortening (plication) suture dehiscence after pericardial patch individualized decision implantation (invasiveness of plan B) Re-repair, if mechanism of failure can predictably be eliminated
15 Conclusions With the use of eh as indicator for cusp prolapse and gh as indicator for cusp retraction, the most common reasons for failures after aortic valve repair can be avoided. Reoperation after failure is possible with a low hospital mortality. Identification of mechanism of failure allow re-repair in some patients.
16 Insufficient commissural height 45 year old female with recurrent regurgitation after reimplantation of a BAV 6 months ago Intraop findings: BAV: Fusion of right and noncoronary cusp Prolapse of both cusps limited perforation of the left cusp insufficient commissural height AV diameter 25mm
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