Joseph E. Bavaria, MD
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1 EACTS Master Class on Aortic Valve Repair Joseph E. Bavaria, MD Director, Thoracic Aortic Surgery Program Roberts Measey Professor and Vice Chair of CV Surgery University of Pennsylvania Immediate-Past President STS
2 Can we decrease late Proximal Aortic Complications of Re-operation, Aneurysm and AI?
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4 Cause of death Acute CHF due to AI Coronary malperfusion Cerebral malperfusion Free Ascending rupture Treatment Aortic valve resuspension Aortic root repair Arch replacement Asc aortic replacement
5 Aortic Dissection: Mechanisms of Aortic Regurgitation Normal Resuspension Tethering Reimplantation (Root) Prolapse Resuspension/Neo-Media Prolapsing Flap ResuspensionNeo-Media TEE ME AoV LAX Movsowitz JACC 2000;36:884
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7 Marfan s (Sinus Aneurysm; 5-10%) Bicuspid Valve or Primary Valve leaflet abnormality (10-15%) Intimal Tear (not dissection) into sinus segment (Could do a David V in this situation) (not simply a dissection down to the annulus)?? Does the presence of Dissection layers into the Root = Re-implantation (or a Root)???
8 Malperfusion Syndrome in Acute Type A Dissection: Results/Coronary Coronary Malperfusion is 6-12% of cases Has high Hospital Mortality 31% with vs 11% without in Penn Series Multivariate odds ratio = 5.1 for in-hospital mortality from Emilia- Romagna AAD registry 56% Needed Root Replacement and 63% Coronary Revascularization (Usually RCA graft) The Reason WHY Root Replacement has a 2.5 Odds ratio for 30-day mortality: Penn Series n= 490, 2011 No difference in Native CAD... All Result of dissection
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12 Type A (Debakey Type I) Dissection: Pre and Post Proximal Repair with FET Distal Graft: Note Root Repair and AI Severe AI No AI Repaired Valve/Root
13 Aortic Valve Resuspension
14 ROBUST: Aortic Root Reconstruction/Sinus of ValSalva Repair Bavaria, Pochettino, Gleason, et al; Ann Thor Surg 2003
15 Bavaria JE, et al; AATS 2001
16 Completed Root Repair and Aortic Valve Resuspension with Neo-Media Bavaria, Pochettino, Gleason, et al; Ann Thor Surg 2003 IMPORTANT: 72% of Aortic Roots/Valves were NORMAL prior to Dissection!
17 Aortic Valve Resuspension
18 Aortic Root Neo-media (Aggressive)
19 Proximal Intussuscepted Anastomosis after Root Repair with Neomedia and Resuspension
20 Note: Finished Product, Efficient Conduct of operation; Classic operation
21 Freedom From Proximal Reoperation Acute Type A Dissection: Freedom from Proximal Re- Operation using Neo-Media Resuspension and the Penn Survival Analysis Aortic Root Decision algorithm 1.0 1, ,8 Survival 0.6 0, ,4 91% (+/- years 0.2 0, ,0 Patients at risk: Time (years) STS Jan 2014; Desai, Bavaria, et al, Ann. Thor. Surg 2014 Figure 5
22 Felt neo-media: Proximal and Distal anastomosis (hemiarch): Type A Dissection Repair
23 Data and Outcomes
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25 Supra coronary No isolated Resuspension +/- glue 11% re0p in survivors 92% Freedom from 5 yrs.
26 119/152 had this index operation ( ) No isolated Resuspension or Aggressive Root procedure except use of glue 10% Proximal Reoperation 5.4 years This is not very satisfactory
27 Root Sparing Techniques - Freedom from Aortic Root Events = 92% at 10 years - Growth of Aortic Root = 0.4 mm/year (very slow)
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29 Freedom from Aortic Valve reoperation (preserved 10 yrs = 85.6% For Freedom from Proximal operation was 89% (20/ years (60% valve; 40% Root)
30 28/37 (76%) Debakey I had Root repair with Resuspension Mean F/U = 50 months Only 2/37 (5.4%) needed Proximal Reoperation
31 196 consecutive patients ( ) Aggressive resuspension and root repair ONLY one proximal reoperation (10 distal reoperations) 99% freedom from proximal reop at 4 years
32 N= 104/592 Mean F/U = 6.5 yrs Restoring the Root Geometry at STJ, Resuspension, obliteration of any flap extension into root = Lower Rate of Proximal Reoperation (p=.009) Must obviate a Pathological evolution of the Aortic root
33 K. Yamanaka et al; EJCTS 2012 N=140 ( ); 9.3% operative mortality Zero proximal aortic mean 44 months Geirsson and Bavaria (initial series 2007) 95% freedom from proximal reoperation Note: The Bioglue repair era
34 Are These data equal or as good as Reimplantation?? Yes For Type A Dissection
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36 Freedom from Aortic Reintervention after VSRR in acute type A aortic dissection Mean = 40 months At 9-year follow-up, the rate of freedom from proximal aortic reintervention was 100%, and that of freedom from distal aortic reintervention was 80% Leshnower Chen. Ann Thorac Surg 2015;99:
37 208/374 patients received a Root Procedure 78 received a Valve Sparing Procedure Valve Sparing Root surgery showed NO Difference in mid-term results with Bentall 5% proximal reoperation rate for Valve Failure at mean = 4 years
38 N= 59 patients with Remodeling Valve Sparing Root procedure with Type A Dissection and Aortic Root > 45 mm -Freedom from Proximal Reoperation = 98% at 10 years excellent results
39 Address the Root aggressively Do Root procedures in the appropriate cases:. DV unless Leaflets abnormal Sinus Dilation Extensive Destruction of Root? left Cusp Intimal TEAR into Sinus segment Marfans/BAV Otherwise repair the Root/Valve and get good results
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41 Recently = 20% of Penn cases over past 3 years In Patients with a > year life expectancy (<60 years) In Patients who have Normal Aortic valves and have a Root indication (best cases!) Excellent in Debakey II (with above) In Patients where an aggressive Root Restoration Neo-Media Resuspension may be difficult Caution in patients who require Total Arch or Extended Arch operations. Too much??
42 Re-implantation (+ Total Arch) in Type A Dissection 20 patients with Acute Type A Dissection and Total Arch procedure - 0% Mortality; 0% CVA - Freedom from +3 or +4 AI = 83% at 5 years
43 It is the one case type where I use the Cameron 3 Stitch (Sub-annular) technique at the primary suture line. Use a slightly smaller graft as the annulus is usually smaller in these ACUTE cases Nuance: Also because sometimes the aorta has to be cut very close to the annulus so you don t want to pull the Coaption apart Careful about dissected RCA Button Recently = 20% of Penn cases over past 3 years
44 Questions?
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