State of the art in reconstruction of the ascending aorta with or without valve reconstruction PD Dr Diana Aicher Universitätskliniken des Saarlandes Homburg/Germany ESBV Straßbourg, May 10 2013
Background Atherosclerosis, connective tissue disorders, and congenital aortic valve abnormalities (bicuspid or unicuspid anatomy) cause aneurysmatic dilatation of the ascending aorta. Operative replacement of the dilated aorta is necessary to avoid complications like dissection or rupture.
Background If dilatation includes the aortic root, combined replacement of the valve and ascending aorta is necessary. Standard technique is the Bentall procedure. Alternative techniques are valve-preserving techniques.
Valve sparing aortic root replacement Remodeling Sarsam/Yacoub 1993 JTCVS 105;3:435-438 Reimplantation David 1992 JTCVS 103;4:617-621
Replacement of the ascending aorta with preservation of the valve Abscence of calcification/valve stenosis Root dilatation (Sinus > 42-45mm) ± regurgitation Sinutubular junction Sinus Aortoventricular junction
Remodeling of a bicuspid aortic valve Operative Steps: 1. Root assessment: TEE (long axis): AV diameter sinus diameter ST diameter
Remodeling of a bicuspid aortic valve Operative Steps: 2. Exposure: standard cannulation longitudinal incision transsection of aorta (5mm above commissures) stay sutures above commissures
Remodeling of a bicuspid aortic valve Operative Steps: 3. Mobilization of the Root: geometric height AV diameter
Remodeling a of bicuspid aortic valve Operative Steps: 4. Tailoring of the graft: symmetric tonques Incisions for commissures 20% less than anticipated
Remodeling of a bicuspid aortic valve Operative Steps: 5. Suture Graft to Root: from the center of a sinus to the commissures fused cusp (left/right) à non-coronary sinus
Remodeling of a bicuspid aortic valve Operative Steps: 6. Assess cusp configuration: effective height
Remodeling of a bicuspid aortic valve Operative Steps: 7. Reconstruction of AV (AVJ > 25mm)
Remodeling of a bicuspid aortic valve Operative Steps: 8. Final check: TEE: Aortic regurgitation (central, eccentric, degree) configuration of the valve effective height
Valve preserving surgery (10/1995-3/2009) Remodeling Reimplantation p (N=401) (N=29) Age (years) 58 ± 15 42 ± 16 Sex (m/f) 300/101 19/8 Tricuspid AV 271 27 BAV/UAV 124/6 2/- Diagnosis: Aneurysm 336 22 AADA 59 7 CADA 6 - Marfan 13 12 Myocardial Ischemia (min) 82 ± 20 112 ± 24 0.01 Hospital mortality total 13/401 (3.2 %) 0/29 0.32 elective 9/342 (2.6%) 0/22 0.33 emergency 4/59 (6.8%) 0/7 0.08 Kunihara et al. JTCVS 2012 Jun;143(6):1389-1395
Aortic Root Repair (Homburg) 100 80 Survival Aortic Root Replacement (Composite) 84% 68% 47% 60 % 40 20 0 0 12 24 36 48 60 72 84 96 108 120 132 144 Follow-up (months) Etz et al. JTCVS 2007
Freedom from reoperation Kunihara et al. JTCVS 2012 Jun;143(6):1389-1395
Kunihara et al. JTCVS 2012 Jun;143(6):1389-1395
Conclusions Early mortality is comparable after the Bentall procedure and valve preserving root replacement Valve-preserving root replacement leads to excellent long-term valve durability, if a good aortic valve configuration can be achieved Ten-year survival rates after valve-preserving root replacement are superior to survival rates after the Bentall operation With a low rate of valve-related complications valve-preserving root replacement has become an attractive alternative composite replacement of the valve and aorta.
Reimplantation Remodeling
Fries et al. JTCVS 2006; 100;132:32-37
Sinutubuar junction remodeling