Lessons From The Computer Model and How We Do Root Replacement

Transcription

1 Lessons From The Computer Model and How We Do Root Replacement Ehud Raanani, MD Cardiac Surgery Leviev Cardiothoracic and Vascular Center Sheba Medical Center Sackler School of Medicine, Tel Aviv University

2 Outline Lessons from the computer model How we replace the aortic root our results

3 Mechanisms of AR in many cases is a combination of: Root pathology Asc. Aortic aneurysm (STJ) Root aneurysm: STJ Annular dilataion Cusp pathology Cusp Prolapse Calcific degeneration Commissural pathologies

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5 I. Patients with root enlargement have dilated aortic anulus :25-30mm

6 Courtesy A. Hamdan

7 Freedom from reoperation after repair in patients with preoperative AVD of >28 mm depending on the use of root replacement. Significant failure in patients with a > 28 mm Annulus whether they have a SCA or Remodeling Root. Aicher D et al. Circulation 2011;123:

8 Effect of annulus diameter Six geometries with different annulus diameters Calculated by expanding or shrinking the AA of normal case (24mm) The other dimensions were not changed 20mm 22mm 24mm 26mm 28mm 30mm C-C section

9 Influence of the geometry on coaptation 5 4 average h c [mm] h C average h C [mm] geometric height [mm] 3,5 3 2,5 2 1,5 1 0, AA diameter [mm]

10 Dilated Annulus, What are the surgical options? Sub-Commissural Annuloplasty

11 BAV repair (SCA): fails in the short term p = years 34 ± 12% 94 ± 5% 86 ± 10% J. Bavaria et al: STS 2013

12 JTCVS 2011

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14 Circular Annuloplasty Expansible Band PTFE annuloplasty Lansac 2006 Kazui, Svensson, Schäfers 2007

15 II. The Effective Height Concept

16 Coaptation vs. effective height The effective height correlates well with valve coaptation The cusps in all the cases with h E <9mm prolapsed during diastole 5 4,5 4 3,5 h E h c [mm] 3 2,5 2 1,5 1 0, h E [mm] daa cusp area

17 III. BAV NFC angles ( degrees)

18 160º

19 4 BAV geometries with different NFC angle Method s Four common BAV geometries were generated, include one raphe and different NFC angles from 120 to

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21 Effective Orifice Area (EOA) at Peak Systole θnfc EOA [cm²] Increased NFC angle followed by decreased effective orifice area and centered opening

22 Echo Results Taken from 12 non-pathologic BAV patients NFC Angle Echo Video Number of Patients EOA 2.5 [cm²] 3.35 [cm²] 3.65 [cm²] Velocity 1.83 [m/s] 1.55 [m/s] 1.41 [m/s] Pressure Grad. 14 [mmhg] 10 [mmhg] 8.4 [mmhg] Max Opening

23 EOA- Model Vs. Echo Conclusions The same opening pattern: Decreased NFC angle followed by increased effective orifice area and eccentric opening

24 FSI results: Jet Flow Velocity and direction

25 Flow Velocity - Peak Systole Results Jet flow velocity of the four geometries during peak systole (time of sec):

26 The structural and the jet flow velocity simulations for the 140 model, during systole 140

27 Stress Distribution Diastole Diastole (Time 0.34 [Sec]) θnfc

28 Flow Shear Stress - Peak Systole (LV side view, time=0.115) NFC Fuse d cusp

29 FSI models Both FSI and Dry Dry models Summary: Models Performance Scores Jet Flow Direction Flow Shear Stress EOA Stress Diastole Conclusions Tradeoff Between the jet flow direction to the effective orifice area The minimal stresses distribution were found in the 160 model The inadequate performance of the 120 model can explain the early failure of BAVs with NFC angle<160

30 Freedom from reoperation BAV repair depending on the orientation of the 2 normal commissures Aicher D et al. Circulation 2011;123:

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32 Root Replacement

33 RE-Implantation (David)

34 Valsalva Graft

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37 Graft Sizing- depending on GH 2/3 of Average GHmm X 2 +4 mm Example : 2/3 of 18mm=12mm X 2= 24mm+4=28mm graft

38 Re-implantation BAV

39 Patients: patients AVSS 81(36%) Root 97 (43%) STJ 49 (21%) Isolated Cusp 1818% (22%) Cusp UAV/BAV intervention 4347% (44%) Cusp UAV/BAV intervention 41% UAV/BAV

40 Surgical Procedure 13 cases (6%) were Redo surgery 50 patients (22%) underwent concomitant procedure 39 patients (17%) hemi/arch replacement

41 Early Results 1 patient died, (0.4% of in hospital mortality) Major Complications: CVA 2 (0.9%) Acute Kidney Injury 8 (3.5%) Pacemaker 5(2.2%)

42 Late Results Mean FU time was 75±37 months Clinical FU was completed to 100% Echo follow up was completed to 97%

43 Late Survival There were 15 cases (6.6%) of late death Overall survival rate for 5 years was 94.4%

44 Late Clinical Outcomes At FU, 208 (91.6%) patients were NYHA class l or ll. Re-operation: 16 pts (7%) Freedom from re-operation or severe AI in 5-years of follow-up was 87.6%

45 Freedom from AI or Re-operation (in Patients who Underwent Replacement of Aorta)

46 Pericardial Patch for Partial Cusp Replacement

47 Pericardial Patch Augmentation

48 Patients with Cusp Repair Predictors for Failure

49 Freedom from reoperation after repair depending on the use of a pericardial patch Other materials(cor-matrix, Gortex membrane, Cardiocell) Aicher D et al. Circulation 2011;123:

50 Summary Low operative risk, morbidity and mortality rates Good early and late functional state However, significant recurrence if cusp repair is needed, especially if pericardial patch is used Failure is due to calcification and degeneration of the patch An alternative for pericardial patch is needed

51 Thank you