aortic valve repair: when and how to employ this novel approach? · 2018. 8. 24. · aortic valve...

Aortic valve repair:

When and how to employ

this novel approach?

Konstadinos A Plestis, MD

System Chief of Cardiac Thoracic and Vascular Surgery

Main Line Health Care System

Professor Sidney Kimmel Medical College

Thomas Jefferson University

Aortic Valve

LANKENAU HEART INSTITUTE

Normal Aortic Valve

•Aortic cusps

•Aortic annulus

•Valsalva sinuses

•Commissures

•Sinotubular junction

The functional aortic annulus (FAA)

Aortic Valve Regurgitation

Khourhy Classification

• Functional Annular dilatation: type 1

• Leaflet Prolapse: type 2

• Leaflet Restriction: type 3

Mechanism of Aortic Regurgitation

ANNULAR DILATATION - Type 1

STJ dilatation STJ+AVJ dilatation AVJ dilatation

Mechanism of Aortic Regurgitation

CUSP PROLAPSE – Type 2

Aortic Valve Repair for Aortic Regurgitation

Sino-tubular

Junction dilatation

Type Ia: Sinotubular dilatation

Type Ib: Aortic root aneurysm

Aortic root

aneurysm

Type Ib: Aortic root aneurysm

Aortic root

aneurysm

Type Ib: Valsalva Sinus Aneurysm

Sinus of Valsalva

aneurysm

Annular dilatation

Type 1c: Annular dilation

Type Id: Cusp perforation

Cusp perforation

Type Id: Cusp perforation

Leaflet perforation

Type II: Flail aortic cusp

Cusp prolapse

Type II: Flail aortic cusp

Type II: Partial cusp prolapse

Cusp prolapse

Type III: Heavily calcified valve

Cusp restriction

Anatomy of the Root

Effective Height

Schafers H.-J. et al.; J Thorac Cardiovasc Surg 2006;132:436-438

Effective Height

Isolated leaflet prolapse

Aortic Leaflet Plication

Subcomissural annuloplasty

Indications for Aortic Valve Repair

• Tricuspid or bicuspid aortic valves

• Aortic Valve Regurgitation

• Valve leaflets without calcification, fibrosis or multiple

fenestrations

• Root Aneurysm

• Selective endocarditis cases

Bicuspid Aortic Valve Repair

Mini Sternotomy

Ascending Aneurysm Replacement

Case Presentation

Bicuspid Aortic Valve Repair - Extension

31 yo female

•Asymptomatic

•Severe AI

•Bicuspid AV

•Ascending aortic aneurysm

Endocarditis

32 yo male

•Endocarditis

•Bicuspid AV

•NCC perforation

•Severe AI

•Annular dilatation

Aortic Valve Repair Outcomes

Outcomes

Age 59±15

Males 116 (74%)

Aortic Valve Repair

Tricuspid AV 131 83%

Bicuspid AV 26 17%

Endocarditis 8 5%

Concomitant Procedures

David procedure 23 15%

Total Arch Replacement 6 4%

Hemiarch 31 20%

MVR 9 6%

CABG 20 13%

Complications

Mortality 2 1.2%

Stroke 4 2.5%

New RI 3 1.9%

PVS 22 14%

PVS-Prolonged Ventilatory Support

RI- Renal Insufficiency

Bleeding 5 3%

Afib 35 22%

CHF 4 2%

CHF- Congestive Heart Failure

Complications

Follow up

Mean Follow up: 5 yrs

Freedom from AI > 2+ : 93%

Freedom from reoperation: 94%

Literature Review

Aortic Valve Repair

El Khoury

(n=122)

El Khoury

(n=475)

Schafers

(n=640)

Holubec

(n=100)

Svensson

(n=720)

Age 44 53 56 51 42

Male 92% 81% 73% 73% 87%

Acute Dissection N/A N/A 10% N/A N/A

BAV 100% 35% 32% 60% 100%

TAV 0% 65% 64% 40% 0%

43% 34% 47% 82% 85%

Aortic Dilatation

14% 46% 39% 67% N/A

AI and Dilatation

43% 19% N/A N/A N/A

Aortic Valve Repair

El Khoury

(n=122)

El Khoury

(n=475)

Schafers

(n=640)

Holubec

(n=100)

Svensson

(n=720)

Raphe Repair 80% N/A N/A N/A Yes

Cusp Prolapse

Repair 65% N/A 83% 70% Yes

Annuloplasty 42% 32%

47% Yes

Reimplantation 34% 41% 50% 12% N/A

Remodeling 10% 10%

44% N/A

Aortic Valve Repair

El Khoury

(n=122)

El Khoury

(n=475)

Schafers

(n=640)

Holubec

(n=100)

Svensson

(n=720)

Mortality 0% 0.8% 3.4% 0.8% 0.4%

Stroke 0.8% 1.1% N/A N/A 0.3%

Aortic Valve Repair

El Khoury

(n=122)

El Khoury

(n=475)

Schafers

(n=640)

Holubec

(n=100)

Svensson

(n=720)

1 year 98%

3 years 84%

5 years 94% 91% 87% 51%

10 years 85% 81%

Freedom from Moderate or Severe Aortic Insufficiency

Aortic Valve Repair

El Khoury

(n=122)

El Khoury

(n=475)

Schafers

(n=640)

Holubec

(n=100)

Svensson

1 year 98% 95%

5 years 94% 94% 93% 89% 87%

10 years 83%

86% 86% 87% 78%

15 years 64%

Freedom from Reoperation

Aortic Valve Repair

El Khoury

(n=122)

El Khoury

(n=475)

Schafers

(n=640)

Holubec

(n=100)

Svensson

(n=720)

1 year 99% 99%

5 years 93% 92% 94% 97%

10 years 73% 80% 94%

20 years 82%

Long Term Survival

Conclusions

• Aortic valve repair has evolved significantly

• Results are reproducible

• 10 year outcomes are excellent

Thank You

Patch Repair

Central Cusp Plication Technique

Free Margin Resuspension

with 7/0 PTFE suture

Minimally Invasive Procedure

• Excision of the vegetations of the conjoined leaflet

•Repair of perforation of NCC

• Free edge plication of conjoined leaflet

• Annuloplasty to 25 mm

Type II: Whole cusp prolapse

Cusp prolapse

Case Presentation

Isolated Tricuspid Valve Repair

45 yo male

• Increasing SOB

• Severe AI

• Rupture of fenestration

• Leaflet prolapse

Procedure

• Aortic valve repair

• Patch of the fenestration

• Free edge plication

• Subcomissural annuloplasty

• MV Repair

Case Presentation

AV repair, External Annuloplasty

61 yo male

• Increasing shortness of breath

Preoperative Diagnosis

• Severe aortic valve regurgitation

• Bicuspid aortic valve

Procedure

• Aortic valve repair

• Conjoined left and right leaflets

• Free edge plication

• Circumferential external annuloplasty

• Sinotubular junction fixation

Comorbidities

Hypertension 118 75%

Diabetes 15 10%

COPD 21 13%

Renal Insufficiency 13 8%

Stroke 13 8%

Aortic Valve Repair

Emergent 24 15%

Urgent 27 16%

Redo 10 6%

Operative times

Pump time 169±56

Cross Clamp time 123±52

PRBC 2.0±3.0

FFP 1.5±2.0

Platelets 1.4±2.2

Cryoprecipitate 1.5±3.6

Blood Utilization

Aortic Valve Repair

El Khoury

(n=122)

El Khoury

(n=475)

Schafers

(n=640)

Holubec

(n=100)

Svensson

(n=720)

CPB 106 114 N/A 115 66

95 N/A 93 49

Tricuspid Aortic Valve Repair

aortic valve repair: when and how to employ this novel approach? · 2018. 8. 24. · aortic valve...

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