Repair for Aortic Regurgitation: is it durable?

Repair for Aortic Regurgitation: is it durable? Gébrine El Khoury Cliniques Universitaires St-Luc, IREC, UCL, Brussels, Belgium AATS 95 th Annual Meeting 25-29 April, Seattle

Aorrtic valve repair the basics -role of the functional aortic annulus:faa dilation -role of the free margin of the leaflets:fm elongation

Yacoub David

First «basic»: Aorrtic valve repair the basics Despite of normal leaflets, root aneurysms (FAA Dilation) may induce aortic regurgitation, and the restoration or recreation of normal root (FAA) corrects the regurgitation. Concept: LESION DYSFUNCTION TREAT THE LESION, CORRECT THE DYSFUNCTION

Leaflet prolapse:excess length of free margin, shortening (plication) correct prolapse and AR

Aorrtic valve repair the basics -Second «basic»: Leaflet prolapse: excess length of free margin shortening (plication) of the free margin correct prolapse and AR

Aorrtic valve repair the basics -third «basic» -Close relationship betweec FAA and FM leaflet coaptation and MOTION -close relationship between FAA and AR FAA dilation AR

Understanding Valve Dysfunction Classification of Dysfunctions Echocardiographic Assessement Classification Surgical Assessement STJ Sino-tubular Junction; SCA Sub-Commissural Annuloplasty Dysfunction etiology lesion repair JTCVS 2009;137:286-94

Functional classification of aortic regurgitation Mechanism of AV dysfunction Type 1 AR : FAA dilatation Type 1a (STJ) Type 1b (STJ+VAJ) Type 1c (VAJ)

AV repair for AI: Mechanisms of AI Cusp perforation (Type 1d)

AV repair for AI: Mechanisms of AI Cusp prolapse (Type 2)

AV repair for AI: Mechanisms of AI Restricted cusp motion (Type 3)

Fundamental Principles of Valve Repair - Preserve or restore normal motion Leaflets - Create a large surface of coaptation - Remodel and stabilize the annulus Close functional relationship (functional unit)

Valve repair and durability Determinants of durabilty: Quality &quantity of tissue, patient selection Appropriate surgical technique - Excellent immediate result of repair Leaflet coaptation,motion FAA stabilisation Long term durability

AV repair for AI: Determinant of durability A. Quality & quantity of tissue, patient selection B. Appropriate surgical technique

AV repair for AI: Etiology Congenital - Moncuspid - Bicuspid - Quadricuspid - Connective tissue disorders (Marfan, Loeys-Dietz, Ehler- Danlos, Familial Aneurysmal disease, )

AV repair for AI: Etiology Acquired - Degenerative cusp - Degenerative aortic aneurysm (Atherosclerosis) - Traumatic - Infectious - Acute aortic dissection

AV repair for AI: Etiology Redo - Ross repair - Re-repair

Valve repair and durability Determinants of durabilty: Quality &quantity of tissue, patient selection Appropriate surgical technique - Excellent immediate result of repair Leaflet coaptation,motion FAA stabilisation Long term durability

AV repair for AI: Actual requirement Optimal coaptation + Stabilisation Effective height (eh) 9 mm Coaptation length 4 mm Circumferential annuloplasty VAJ >26 mm No residual AR Pethig K. ATS 2002 le Polain de Waroux JB. JACC Card. Im. 2009 Bierbach BO. EJCTS 2010 Aicher D. Circ. 2011 De Kerchove L. JTCVS 2011

AV repair for AI: Determinant of durability A. Quality & quantity of tissue, patient selection B. Appropriate surgical technique

AV repair for AI: Mecanisms of AI El Khoury G. Cur. Op. Card. 2005

Supracoronary Ascending Aortic Aneurysms (Type 1A)

Freedom from AV Reoperation Freedom from AV Reoperation 100 80 60 40 20 0 0 24 48 72 96 Months No. at risk 55 41 28 10 3

AV repair for AI: Root dilatation (Type 1b) - VSRR Toronto: 1988 2010, 371 pts, 9% BAV, 50% cusp repair 97% 93% 95% Freedom from Reop 95% 91% Freedom from AR 2+ 78% No predictors of recurrent AR T. David JTCVS 2014

AV repair for AI: Root dilatation (Type 1b) - VSRR Homburg: 1995 2009, 430 pts, 30% BAV, 73% cusp repair Freedom from AV reop. Freedom from AR 2+ T. Kunihara JTCVS 2012

AV repair for AI: Root dilatation (Type 1b) - VSRR Brussels: 1996 2014, 275 pts, 43% BAV, 70% cusp repair 100% 92% S. Mastrobuoni STSA 61 st meeting 2014

AV repair for AI: Root dilatation (Type 1b) in Marfan syndrome Toronto: 1988 2006, 103 pts, mean age 37 y Freedom from AV reoperation Freedom from AR >2+ T. David, JTCVS 2009

vssr+cusp repair

AV Repair for AI: VSRR +/- Cusp repair H.J. Schäfers Ann Thor Surg 2002 L. de Kerchove Circulation 2009

AV Repair for AI: Results Prolapse repair (Type 2) 93% 93% 87% M. Boodhwani, JTCVS 2011

Tricuspidisation and 3 cusps extension

AV repair for AI: Isolated AI Cusp prolapse/restriction/perforation (Type 2,3, 1d) Mayo: 1986 2011, 331 pts, 40% BAV, 100% cusp repair 79% 72% 75% 58% Risk factors of reop: Severe preop AR, > mild AR at discharge Sharma V. JTCVS 2014

AV repair for AI: Predictor of recurrent AI Cusp restriction (Type 3) Freedom from AV reoperation Freedom from AR >2+ (Prolapse) (Restriction) (Prolapse) (Restriction) M. Boodhwani, JTCVS 2009 Cusp Height to define cusp restriction TAV < 16 mm BAV < 19 mm Schafers H.J. JTCVS 2013

AV repair for AI: Predictor of recurrent AI Cusp extension/restoration with Patch Boodhwani M. JTCVS 2010 Aicher D. Circ. 2011

AV Leaflet Repair: Results Leaflet repair with patch Mozala Nezhad Z. EJCTS 2014

Valve repair and durability Determinants of durabilty: Quality &quantity of tissue, patient selection Appropriate surgical technique - Excellent immediate result of repair Leaflet coaptation,motion FAA stabilisation Long term durability

AV repair for AI: Predictor of recurrent AI Coaptation length and height Tips > annulus, No AR Residual AR, Coapt >4 mm Tips > annulus Residual AR Coapt < 4 mm Tips < annulus le Polain JB. JACC Card. Im. 2009

AV repair for AI: Predictor of recurrent AI Coaptation length and height Aicher D. Circ. 2011

Valve repair and durability Determinants of durabilty: Quality &quantity of tissue, patient selection Appropriate surgical technique - Excellent immediate result of repair Leaflet coaptation,motion FAA stabilisation Long term durability

AV repair for AI: Predictor of recurrent AI Large ventriculo-aortic junction BAV repair No circumferential annuloplasty Remodeling Aicher D. Circ. 2011 T. Kunihara JTCVS 2012

AV repair for AI: Predictor of recurrent AI Large ventriculo-aortic junction Non-circumferential Subcommis. Annuloplasty (Cabrol stitch) BAV repair TAV repair Navarra E. EJCTS 2013 de Kerchove EJCTS 2015

AV repair for AI: Predictor of recurrent AI 0 0 2 4 6 8 10 Large ventriculo-aortic Years junction Pts at risk VAJ 27 117 92 61 44 23 7 VAJ >27 18 13 8 1 Circumferential annuloplasty in VS Reimplantion B % 100 80 60 40 p=0.38 VSR VAJ 28mm VSR VAJ 28mm 20 0 0 2 4 6 8 10 Pts at risk Years VAJ 27 88 52 35 18 8 2 VAJ >27 56 44 33 18 9 6 De Kerchove L. EJCTS 2015

AV repair for AI: Predictor of recurrent AI Large ventriculo-aortic junction Matched comparison VSR vs SCA 100 80 p=0.0006 % 60 40 20 Freedom from AR>1+ Group SCA 1 Group VSR 2 6 years 64±15% 95±5% 0 0 12 24 36 48 60 72 84 96 Months No. at risk Group 1 53 42 33 27 21 18 15 10 8 Group 2 53 39 29 23 20 14 9 6 2 De Kerchove L. JTCVS 2011

AV Leaflet Repair: Conclusions The mechanism of AR are actually well understood and the use of a classification of AR help to plan AV repair. Surgeon dispose of a wide armamentarium of repair techniques adapted to the variety of valvular lesions. Durability of leaflet repair depend on the quality and quantity of tissues; long term results are excellent for prolapse repair and acceptable for repair of restrictive lesion. Next to leaflet tissues quality, optimal valve coaptation and annuloplasty are other determinants of repair durability. Still, longer follow-up is necessary to investigate 2 decade after aortic valve repair.

AV repair for AI: Conclusions Is it durable? Yes Respect determinants of durabilty: Quality & quantity of tissue, patient selection Type 3 (calcif., short geom. height), patch repair Appropriate surgical techniques Optimal cusp coaptation, motion FAA stabilisation

Thank you

AV repair for AI: Patient demographic Mean age of patient with isolated AI: - 57 y Roberts WC. Circulation 2006-53 ± 14 y Sharma V. JTCVS 2014-59 y (TAV) vs 40 y (BAV) De Meester C. AHA 2012 Mean age of patient with aortic aneurism ± AI - 47 ± 15 y T. David JTCVS 2014-57 ± 15 y T. Kunihara JTCVS 2012-44 ± 11 y (BAV) F.A. Kari ICVTS 2014

Bioprosthesis durability in pts < 60 y Johnston D.R. Ann Thor Surg 2015 Bourguignon T. ATS 2015 20 30 % of SVD @ 15 y

Bioprosthesis durability in pts < 60 y 50 y 55 y 60 y Bourguignon T. Ann Thor Surg 2015 Johnston DR. ATS 2015 > 25 % reop. @15 y for patient < 50 y

AV repair for AI: Hospital mortality in elective surgery 0.6% V. Sharma, H. Schaff JTCVS 2014 0.8% J. Price, G. Elkhoury ATS 2013 0.8% D. Aicher, H-J Schafers EJCTS 2010 1% T. David JTCVS 2014

AV Repair: Long term Survival 81% V. Sharma, H. Schaff JTCVS 2014 90% 81% 73% 90% 80% 77% J. Price ATS 2013 T. David JTCVS 2014

AV repair for AI: Patients Mean age of patient with severe AI: 50 ± 17 year - Tricuspid 59 ± 14 year - Bicuspid 40 ± 13 year De Meester C. AHA 2012 Johnston DR. ATS 2015 Bourguignon T. ATS 2015

Bioprosthesis durability in pts < 60 y Johnston DR. ATS 2015

Bioprosthesis durability in pts < 60 y Bourguignon T. Ann Thor Surg 2015

Bioprosthesis durability in pts < 60 y Johnston D.R. Ann Thor Surg 2015 20 30 % reoperation for SVD @ 15 y

AV repair for AI: Root dilatation (Type 1b) Homburg: 1995 2009, 430 pts, 30% BAV, 73% cusp repair Freedom from AR 2+ T. Kunihara JTCVS 2012

AV Leaflet Repair: Results Long term outcomes (1995 2010 : 475 pts, 68% leaflet repair) 84% 86% J. Price ATS 2013

AV Repair: Freedom from Reoperation & AI Authors Period Cohort Technique H. Schaff JTCVS 2014 1986-2011 331 Cusp 100% Sparing 0% FF AV Reop FF recurrent AR >2+ 10 y 80% 10 y 75% T. Kunihara JTCVS 2012 1995-2007 640 Cusp 80% Sparing 50% 10 y 88% 10 y 80% J. Price ATS 2013 1995-2010 475 Cusp 68% Sparing 50% 10 y 86% 10 y 85% T. David JTCVS 2014 1988-2010 371 Cusp 50% Sparing 100% 10 y 97% 18 y 95% 10 y 93% 18 y 78% Root pathology > Cusp pathology

AV repair for AI: TAV versus BAV Freedom from reoperation BAV 84% (7 y) Casselman JTCVS 1999 81% (10 y) Aicher EJCTS 2010 81% (10 y) Price ATS 2013 < TAV 94% (12 y) David JTCVS 2010 93% (10 y) Aicher EJCTS 2010 89% (10 y) Price ATS 2013