The Bicuspid AV Surgical Conisiderations

Transcription

1 The Bicuspid AV Surgical Conisiderations Ehud Raanani, MD Cardiothoracic Surgery, Sheba Medical Center Sackler School of Medicine, Tel Aviv University MAY 15, 2014 Homburg

2 BAV Repair Congenital variations Dysfunction mechanisms Decision making is complex borderline diameters, to root or not? cusps with moderate calcifications Surgical techniques: Stabilization of the root is important annuloplasty is crucial SCA is not a good solution in the BAV but there is no standard technique yet

3 BAV Prevalence 1 2 % Fusion left-right 86 % right-non 12 % left-non 3 % Associated with: Coarctation PDA Turner s syndrome VSD Supravalvar AS William s syndrome Shone s syndrome

4 Frequency of BAV in AVR pts TAV BAV UAV 45 % 49 % 5 %

5 70% 45% 33% 45% of patients between years 70% of patients between years!!

6 Different angles ( degrees)

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

10 Perfect BAV <1%

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12 Unicuspid Aortic Valve unicuspid bicuspid R. Anderson

13 Unicuspid AV Eccentric Opening

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18 Mechanisms of AR in BAV Asc. Aortic aneurysm (STJ) Root aneurysm( STJ/Annulus) Cusp Prolapse Calcific degeneration Root pathology Cusp pathology

19 BAV Cusps Pathology Cusp Prolapse Raphe fibrosis and caification Fenestration Perforation

20 Cusp Prolapse

21 Fibrotic and Redundant Raphe

22 Tissue Deficiency (geometric height< 18-20mm)

23 Calcified Raphe Pericardial Patch Partial Cusp Replacement

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

25 Commissural Pathologies

26 BAV Aortopathy

27 BAV Aortopathy

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30 Risk of late aortic events after an isolated aortic valve replacement for bicuspid aortic valve stenosis with concomitant ascending aortic dilation 153 pts Ascending aortic surgery was required in five patients (3%) Freedom from aortic interventions at 10 and 15 years was 97 and 94%, respectively. No documented aortic dissection or rupture occurred. In a group of patients presenting with aortic insufficiency, freedom from adverse aortic events was significantly lower (88 and 70% Girdauskas E..Borger MA et al, Eur J cardiothoracic surgery Nov 2012

31 Dysfunction of Aortic Root Causing AR Sinu-tubular Dilatation Sinu-tubular +/or Annular Dilatation

32 To Root or Not to Root

33 Freedom from reoperation after BAV 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 ( many of BAV patients) whether they have a SCA or Remodeling Root. Aicher D et al. Circulation 2011;123:

34 Freedom from reoperation after BAV repair depending on operative technique. Root stabilization is important Aicher D et al. Circulation 2011;123:

35 Ascending Aorta Replacement

36 Ascending Aorta Plication for Moderate Dilatation(40-45mm)

37 Root Remodeling (Yaacoub)

38 Remodeling and Correction of Dilated Annulus (D3, Lansac)

39 Physiological and standardized approach to aortic valve repair + = Remodeling Reimplantation Remodeling + subvalvular annuloplasty

40 Re-Implantation (David)

41 Reimplantation BAV

42 What are the normal diameters of the aortic root? Roman 1987 Kim 1996 Nistri 1999 Varnous 2003 Maselli 2005 Babaee 2007 Tamas 2007 Soncini 2009 Bierbach 2010 Zhu 2011 N Annular Ø STJ Ø STJ/ annulus 24.5 (± 3) 27.5 (± 3) 23.4 (± 2.4) 28.1 (± 3.2) 22.7 (± 2.7) 24.7 (± 2.8) (± 3) 31.2 (± 3.7) 24.4 (± 4.1) 22.3±1,4 ( ) 25.4 (± 4.1) 26.7±2.2 ( ) 1.2±0.1 ( ) 21.8±2.4 21± 3 21,6 21±2,8 20,3±8,7 29.5±3.1 27± 4 27,3 25± 3,7 23.4±3, ,3 1,2 1,1 Courtesy E Lansac

43 BAV have dilated AV junction:25-30mm

44 Courtesy A. Hamdan

45 Dilated Aortic Annulus Is Very Common in Patients with BAV and AI Is it Important?

46 Freedom from reoperation after BAV repair depending on preoperative AVD. Aicher D et al. Circulation 2011;123:

47 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

48 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]

49 Influence of the geometry on the max. principal stress The average dimensions case (h G =16.2mm, d AA =24mm) σ max [kpa] has the lowest mechanical stress geometrial height [mm] σ max [kpa] AA diameter [mm] Maximum principal stress [kpa]

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

51 Sub-Commissural Annuloplasty

52 BAV repair (SCA) with dilated annulus (> 27mm): fails in short term SAME Conclusion: More Failure in Large Annulus p = years 34 ± 12% 94 ± 5% 86 ± 10% J. Bavaria et al: STS 2013

53 Sub-Commissural Annuloplasy (SCA) vs Reimplantation on AI p =0.03 SCA 5 years 92 ± 6% 62 ± 10% Bavaria et al; Presented at STS 2013;

54 Computer Finite Element Model Stress during peak systole TAV has the largest opening area Highest stress values are found in BAVs with fused cusps Raphe region increases stress magnitudes Max. principal stress [kpa] A TAV BAV no. 2 A BAV no.1 without raphe BAV no.1 with raphe

55 Flow shear stress during peak systole Higher systolic flow shear stresses are found on the cusps of BAVs The TAV model has the lowest shear stress, specifically on the coapting regions Flow shear stress [Pa] TAV BAV no. 2 BAV no.1 without raphe BAV no.1 with raphe

56 Turbulent flow: cacifications distribution TAV BAV no. 1 without raphe Flow velocit magnitu [m/s] BAV no. 1 with raphe BAV no. 2

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58 Techniques for Aortic Annuloplasty Carpentier 1983 Frater 1986 Haydar 1997 Izumoto 2002 Hahm 2006 Lansac 2007 Schäfers 2009 Fattouch 2011 Courtesy E Lansac

59 Lansac 2007 Schäfers 2009

60 Valsalva 45 mm Valsalva<40 mm all Ø < 40 mm Remodeling + subvalvular annuloplasty Supra-coronary graft + subvalvular annuloplasty (annulus > 25 mm) Subvalvular annuloplasty (annulus> 25 mm)

61 Summary BAV repair for AI, with or without Root Aneurysm, is a good operation in selected patients However, there are relative contraindications to repair where the results are sub-optimal: Significant calcification Need for patch augmentation Inter-commissural angle<160 degrees The case of the Large Annulus (>28mm) specially in Normal Root Diameter SCA can be used selectively but is probably not the best option for dilated annulus

62 Thank you

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65 Survival After the Bentall Procedure in BAV Survival nearly same as age and sex matched group at 12 years 1 Etz C. D. Ann Thorac Surg 2007;84: mount sinai NY

66 Excellent Aortic Bio-Root replacement outcomes in patients < 60y Desai, annals thorac surg 2011; U-penn

67 TAVI Valve-in-Valve Adds More Years to the Index Operation Webb Circ 2010 Bapat JTCVS 2012

68 Fenestration or Perforation Closure and Stabilisation with pericardium

69 Aortic root aneurysm Valsalva 45 mm Supracoronary aneurysm Valsalva<40 mm Isolated AI all Ø < 40 mm Remodeling + subvalvular annuloplasty Supra-coronary graft + subvalvular annuloplasty (annulus > 25 mm) Subvalvular annuloplasty (annulus> 25 mm) Courtesy E. Lansac

70 Freedom from reoperation for SVD All Patients < 60 years

71 Surgical Solutions Geometry altered by non-pressurized state! Stay sutures

72 Aortic Annuloplasty

73 Composite AVR

74 LVOT and Aortic Root Complex

75 Co-Location

76 Remodeling and Correction of Annulus (D3) Dilated

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83 Fibrotic and Redundant Triangular Resection

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87 Aortic Valve Replacement Thromboembolism Anticoagulation/Hemorrhage Structural failure PV endocarditis Incidence of valverelated complications Hammermeister et al, JACC 2000

88 Prolapse Plication of Cusp Margin

89 Dilatation of the STJ

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91 Position of His bundle Position of RCA Ostia

92 Velocity vectors and streamlines TAV BAV no. 1 without raphe Flow velocity magnitude [m/s] BAV no. 1 with raphe BAV no. 2