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)


STJ

AVJ

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: 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


Cusp prolapse

Type II: Flail aortic cusp


Type II: Partial cusp prolapse

Cusp prolapse


Cusp prolapse

Type II: Partial cusp prolapse


Type III: Heavily calcified valve

Cusp restriction


Cusp restriction

Type III: Heavily calcified valve


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

n=157

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

2010

(n=122)

BAV

El Khoury

2012

(n=475)

Schafers

2010

(n=640)

Holubec

2014

(n=100)

Svensson

2014

(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%

AI

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

2010

(n=122)

BAV

El Khoury

2012

(n=475)

Schafers

2010

(n=640)

Holubec

2014

(n=100)

Svensson

2014

(n=720)

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

Cusp Prolapse

Repair 65% N/A 83% 70% Yes

Annuloplasty 42% 32%

N/A

47% Yes

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

Remodeling 10% 10%

N/A

44% N/A


Aortic Valve Repair

El Khoury

2010

(n=122)

BAV

El Khoury

2012

(n=475)

Schafers

2010

(n=640)

Holubec

2014

(n=100)

Svensson

2014

(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

2010

(n=122)

BAV

El Khoury

2012

(n=475)

Schafers

2010

(n=640)

Holubec

2014

(n=100)

Svensson

2014

(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

2010

(n=122)

BAV

El Khoury

2012

(n=475)

Schafers

2010

(n=640)

Holubec

2014

(n=100)

Svensson

2014

(720)

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

2010

(n=122)

BAV

El Khoury

2012

(n=475)

Schafers

2010

(n=640)

Holubec

2014

(n=100)

Svensson

2014

(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


Cusp prolapse

Type II: Whole 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

2010

(n=122)

BAV

El Khoury

2012

(n=475)

Schafers

2010

(n=640)

Holubec

2014

(n=100)

Svensson

2014

(n=720)

CPB 106 114 N/A 115 66

CC 86

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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