The aorto-ventricular junction in aortic repair

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1 The aorto-ventricular junction in aortic repair Emmanuel Lansac, Isabelle Di Centa Cardiac Surgery Institut Mutualiste Montsouris, Paris, France

Dystrophic roots: a matter of diameters Root aneurysm Aicher 2007 Settepani 2009 Pacini 2009 Lansac 2010 Normal aortic root Echo studies 1987-2011 N 1132 Annulus Ø (mm) STJ Ø (mm) 22.3 (20.5-24.5) 26.

2 Dystrophic roots: a matter of diameters Root aneurysm Aicher 2007 Settepani 2009 Pacini 2009 Lansac 2010 Normal aortic root Echo studies N 1132 Annulus Ø (mm) STJ Ø (mm) 22.3 ( ) 26.7 ( ) N Annulus Ø (mm) ±6.3 Dilated> ( ) mm 25.1±3 27.6±2.5 STJ Ø (mm) ±9.1 Dilated> ( ) mm 45.5± ±11 Supra-coronary aneurysms David 2007 Morimoto 2009 Asano 2012 N Annulus Ø (mm) NA ± Dilated 21.6± ±2.4 STJ Ø (mm) 39 ±9 Dilated= ±3.7 mm 30.7±3.4 Isolated AI Sato 2003 Izumoto 2009 Schäfers 2009 Lansac 2011 N Annulus Ø (mm) 26.1± ± Dilated> ( ) mm 27 28±1.4 STJ Ø (mm) 39.2 ± ± 35.6 ± 14 Dilated ( ) ±2

3 The surgical correction of aortic insufficiency by circumclusion Taylor WJ, et al. JTCVS 1958;35: First subvalvular aortic Beating Heart Right thoracotomy 11 patients, rheumatic disease (8/11)

Subcommissural plication stitches (Cabrol stitches) Plicating U stitches at the base of the interleaflet triangles = partial subvalvular Plicating U stitches at the commissures = partial

4 Subcommissural plication stitches (Cabrol stitches) Plicating U stitches at the base of the interleaflet triangles = partial subvalvular Plicating U stitches at the commissures = partial supravalvular Plication of the interleaflet triangles impairing valve dynamics especially for bicuspid valves significant gradient minimal reduction in aortic annular base diameter Risk factor for bicuspid aortic valve repair failure Useful to protect a commissural repair or as a bailout technique De Kerchove EJCTS 2012 Aicher Circulation 2011

5 Aortic devices Experimental In vivo (18 sheep) Calves roots In vivo (4 calves) In vivo (5 sheep) Duran 1993 Reimold 1994 Gogbashian 2007 Internal ring External ring External band Porcine roots Porcine roots 6 months in vivo (1 calf) Rankin 2011 Internal ring Scharfschwerdt 2011 Internal or external ring

6 Techniques for aortic Isolated AI Carpentier 1983 Frater 1986 Haydar 1997 Izumoto 2002 Hahm 2006 Lansac 2007 Schäfers 2009 Need for standardization Fattouch 2011

Aortic root aneurysm Remodeling of the aortic root Yacoub 1983 + + Treatment of STJ dilation Sinuses of Valsalva + ± Reimplantation of the aortic valve

7 Aortic root aneurysm Remodeling of the aortic root Yacoub Treatment of STJ dilation Sinuses of Valsalva + ± Reimplantation of the aortic valve David Aortic Root expansibility (interleaflet triangles) Treatment of aortic annular base dilation - + external aortic Need for standardization

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

height (+130%) 10% systolic expansibility mimics natural

9 An Expansible aortic ring Reduces aortic annular base diameter in diastole (-15%) Increases cusp coaptation height (+130%) 10% systolic expansibility mimics natural annulus dynamics Protects the repair and reduces cusps stress

10 Standardization based on aortic annulus Ø Valsalva graft Ø (mm) Aortic annular base Ø (Hegar dilators, mm) Extra aortic ring Ø (mm) Subvalvular ring = down size from one size

phenotypes Remodeling + subvalvular Supra-coronary graft + subvalvular (annulus > 25 mm) Cusp repair

11 Dystrophy of the ascending aorta pliable tricuspid valve Aortic root aneurysm Valsalva 45 mm Supracoronary aneurysm Valsalva<40 mm Isolated AI all Ø < 40 mm Standardized approach following phenotypes Remodeling + subvalvular Supra-coronary graft + subvalvular (annulus > 25 mm) Cusp repair Subvalvular (annulus> 25 mm) + Alignment of the cusp free edges Resuspension of cusp effective height Subvalvular external aortic

Suture of the Remodeling Cusp resuspension after the

12 Standardization step by step 6 subvalvular «U» stitches Aligment of cusp free edges prior Remodeling Suture of the Remodeling Cusp resuspension after the Remodeling (effective height 9 mm) Subvalvular ring implantation

13 Root aneurysms: Bicuspid valves 6 subvalvular «U» stitches Aligment of cusp free edges

14 Commissures 2 symmetric neosinuses at 180 Effective height measurement Subvalvular aortic

15 Dystrophy of the ascending aorta pliable bicuspid valve Aortic root aneurysm Supra-coronary aneurysm Isolated AI Valsalva 45 mm Valsalva<40 mm Valsalva<40 mm Supra coronary Aorta >45 mm Supra coronary Aorta < 40 mm Standardized approach according phenotypes Remodeling + sub-valvular Supra-coronary graft + sub-valvular (annulus > 25 mm) Cusp repair Supra-valvular (STJ> 35 mm) Subvalvular (annulus>25 mm) + Alignment of the cusp free edges Resuspension of cusp effective height Subvalvular external aortic

16 Supra-coronary aneurysms Sinus Valsalva < 45 mm 6 subvalvular «U» stitches Aligment of cusp free edges Commissures 2 symmetric neosinuses at 180 Effective height measurement Subvalvular aortic

18 Dystrophy of the ascending aorta pliable bicuspid valve Aortic root aneurysm Supra-coronary aneurysm Isolated AI Valsalva 45 mm Valsalva<40 mm Valsalva<40 mm Supra coronary Aorta >45 mm Supra coronary Aorta < 40 mm Standardized approach according phenotypes Remodeling + sub-valvular Supra-coronary graft + sub-valvular (annulus > 25 mm) Cusp repair Supra-valvular (STJ> 35 mm) Subvalvular (annulus>25 mm) + Alignment of the cusp free edges Resuspension of cusp effective height Subvalvular external aortic

19 Repair for isolated aortic insufficiency 6 subvalvular «U» stitches Aligment of cusp free edges Cusp resuspension (effective height 9 mm) Placement of the open subvalvular ring below the coronaries Final aspect

21 Dystrophy of the ascending aorta pliable bicuspid and tricuspid valves Aortic root aneurysm Valsalva 45 mm Supracoronary aneurysm Valsalva<40 mm Isolated AI all Ø < 40 mm Standardized approach according to phenotypes Remodeling + subvalvular Supra-coronary graft + subvalvular (annulus > 25 mm) Cusp repair Subvalvular (annulus> 25 mm) + Alignment of the cusp free edges Resuspension of cusp effective height Subvalvular external aortic

Next Session Windsor EACTS school Nov 28-29 2014 Paris March

22 Next Session Windsor EACTS school Nov Paris March International Multicenter Registry

The aorto-ventricular junction in aortic repair

The aorto-ventricular junction in aortic repair Emmanuel Lansac, Isabelle Di Centa Cardiac Surgery Institut Mutualiste Montsouris, Paris, France Dystrophic roots: a matter of diameters Root aneurysm Aicher