Presenter Disclosure. Patrick O. Myers, M.D. No Relationships to Disclose
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1 Presenter Disclosure Patrick O. Myers, M.D. No Relationships to Disclose
2 Aortic Valve Repair by Cusp Extension for Rheumatic Aortic Insufficiency in Children Long term Results and Impact of Extension Material P.O. Myers, 1,2 C. Tissot, 3 J.T. Christenson, 1 M. Cikirikcioglu, 1 Y. Aggoun, 3 A. Kalangos 1 1. Division of Cardiovascular Surgery, Geneva University Hospitals 2. Cardiac Surgery, Brigham and Women s Hospital & Harvard Medical School 3. Pediatric Cardiology, Geneva University Hospitals & School of Medicine
3 Disclosures The authors report no conflicts of interest
4 Introduction Surgical management of AI in children is problematic, lack of ideal valve substitute Mechanical: difficult life long anticoagulation, panus formation Bioprosthetic: rapid deterioration and calcification Homo or auto graft: no superiority in rheumatic AI Choudhary et al. J Thorac Cardiovasc Surg 1999;118(3): Aortic valve repair: encouraging mid term results in selected patients Optimal hemodynamic conditions Avoid anticoagulation Allow normal annulus growth
5 Introduction (2) Efforts to improve patients selection and subgroups amenable to repair Cusp extension Developed to address aortic regurgitation due to cusp retraction Our mid term results Actuarial survival 97% at 1 and 3 years Duran C et al. Ann Thorac Surg 1991;52(3): Increase of AI from grade I to II in 2.5% of patients No significant increase in peak systolic gradient No reoperations Kalangos A et al. J Thorac Cardiovasc Surg 1999;118(2):225 36
6 Introduction (3) Other mid term results similar (5.2 and 4.6 year follow up) Bacha et al. J Thorac Cardiovasc Surg 2008;135:552 9 Bozbuga et al. Ann Thorac Surg 2004;77(4): Different pericardial materials used Autologuous / Bovine Fresh / Glutaraldehyde fixed No long term results Grinda et al. Ann Thorac Surg 2002;74(2):438 43
7 Introduction (4) Aim Update our cohort to assess long term results of tailored aortic cusp extension in rheumatic aortic insufficiency in children Assess the results using different extension materials Identify risk factors for reoperation
8 Patients & Methods Retrospective chart review March 1993 July consecutive children Grade III or IV AI with increase in LV dimensions 8 patients with peak systolic AV gradients > 20 mmhg Well documented h/o rheumatic fever (revised Jones criteria) in country of origin
9 Patients & Methods Surgical technique CPB Hypothermia to 28 C until 1999 Normothermia since 2000 Transverse aortotomy 2 cm above RCA Myocardial protection: selective antegrade hyperkalemic crystalloid solution q30min Careful inspection of AV Confirm tricuspid morphology No calcification
10 Patients & Methods Cusp extension material Autologous pericardium 53 (68%) Photofix bovine pericardium 16 (20%) Glutaraldehyde fixed bovine pericardium 9 (12%)
11 Patients & Methods
12 Patients & Methods
13 Patients & Methods
14 Patients & Methods
15 Patients & Methods Variable Entire study population N = 78 Fresh autologuous pericardium n = 53 Glutaraldehyde fixed bovine pericardium n = 9 Photofix bovine pericardium n = 16 p Age (years) 12.3± ± ± ± Male 49 (63%) 33 (62%) 5 (56%) 11 (69%) 0.80 Weight (kg) 33.4± ± ± ± Acute rheumatic carditis 4 (5%) 2 (3.8%) 1 (11.1%) 1 (6.3%) 0.65 NYHA functional class I or II 5 (6.4%) 3 (5.7%) 1 (11.1%) 1 (6.3%) 0.83 III or IV 73 (93.6%) 50 (94.3%) 8 (88.9%) 15 (93.8%) 0.83
16 Patients & Methods Variable Entire study population N = 78 Fresh autologuous pericardium n = 53 Glutaraldehyde fixed bovine pericardium n = 9 Photofix bovine pericardium n = 16 p Concomitant surgery MVP 57 (73%) 40 (75.5%) 5 (55.6%) 12 (76%) 0.45 TVP 8 (10%) 5 (9.4%) 0 (0%) 3 (18.8%) 0.31
17 Patients & Methods Cusp thickening & retraction without prolapse 32 Cusp shaving 17 One cusp prolapse & free edge elongation 31 Non coronary 17 Right coronary 11 Left coronary 3 Two cusp prolapse 13 Right & non coronary prolapse 12 Right & left coronary prolapse 1 Three cusp prolapse 1 Commissurotomy 19
18 Patients & Methods Follow up Before discharge 3, 6 weeks postoperatively in outpatient clinic 6 months, 1 year then yearly in country of origin Followed up to July 2009
19 Patients & Methods Statistical analysis Continuous variables Student t test Wilcoxon signed rank test when appropriate Categorical variables: 2 Differences between cusp extension material groups: ANOVA with Bonferroni post hoc correction Actuarial estimates with Kaplan Meier, log rank Univariate and stepwise Cox multivariable regression analyses to identify predictors of late outcome All statistical tests two tailed, p < 0.05 taken as significant
20 Results Early Outcome Mean aortic cross clamp Isolated AV repair: 73.9±35.2 min (33 144) Concomitant MV and AV repair: 112.1±34.7 min (58 195) Mortality: 1 (LV failure) Morbidity: 2 intraoperative dynamic coronary ostia occlusion by extension patches
21 Results Late Outcome Follow up 76/77 (98.7%) Mean: 115.5±61.4 months Median: 128 ( years) Fresh autologous pericardium: 142±54.9 months Glutaraldehyde fixed bovine pericardium: 43±38 months Photofix pericardium: 71.1±21.3 months Mortality: 1 (at 55 months, sudden cardiac arrythmia)
22 Results Late Outcome Morbidity No thrombo embolic or hemorrhagic events Reoperation for severe aortic valve dysfunction: 15 (19.7%) at 42.9±33.7 months from repair Autologous: 9 (18%) Bovine: 3 (33%) Photofix: 3 (19%)
23 Results Valve function Grade of aortic regurgitation No or trivial 44 (58%) Mild 14 (18%) Moderate severe 7 (9%) Severe 11 (15%)
24 Results Valve function Time point Freedom from reoperation 1 year 96±2.3% 5 years 87.5±3.9% 7 years 84.6±4.3% 10 years 80.7±4.9% 12 years 78.7±5.2% 15 years 75.3±6%
25 Results Valve function
26
27 Results Late outcome
28 Results Transvalvular gradients Variable Fresh autologous pericardium Glutaraldehydefixed bovine pericardium Photofix pericardium Preoperative 17.2± ± ±7.2 Discharge 16.0± ± ±6.9 p a Latest follow up 22.1± ± ±13.7 p b < Increase per year 1.0± ± ±2.4 p c * a: preoperative vs. discharge (Wilcoxon) b: discharge vs. latest follow up c: increase in peak gradient per year using ANOVA compared to * reference
29 Results Ventricular dimensions Variable LVEDD (cm) LVEDD (zscore) LVESD (cm) LVESD (zscore) Preoperative 6.1± ± ± ±1.0 Discharge 4.7± ± ± ±1.2 p < < < < Follow up 4.9± ± ± ±1.8 p < <
30 Results Ventricular dimensions Time point Shortening fraction Preoperative 34.4±3.3% Discharge 23.5±4.3% p < Follow up 30.6±4.1 p < 0.001
31 Limitations Retrospective, non randomized Small sample size Selection bias on cusp extension material Cox proportional hazards modeling limited by number of events
32 Conclusions Aortic cusp extension provides adequate repair in most children with rheumatic aortic regurgitation Fresh autologous pericardium and Photofix pericardium showed better durability, compared to glutaraldehyde fixed bovine pericardium
33 Aortic Valve Repair by Cusp Extension for Rheumatic Aortic Insufficiency in Children Long term Results and Impact of Extension Material P.O. Myers, 1,2 C. Tissot, 3 J.T. Christenson, 1 M. Cikirikcioglu, 1 Y. Aggoun, 3 A. Kalangos 1 1. Division of Cardiovascular Surgery, Geneva University Hospitals 2. Cardiac Surgery, Brigham and Women s Hospital & Harvard Medical School 3. Pediatric Cardiology, Geneva University Hospitals & School of Medicine
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