The aorto-ventricular junction in aortic repair

Size: px

Start display at page:

Download "The aorto-ventricular junction in aortic repair"

Shanon Carter
5 years ago
Views:

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

2 Goals for aortic valve repair treat dilated aortic annulus and STJ Ø preserve root dynamics (neosinuses of Valsalva) preserve expansibility (interleaflet triangles) restore coaptation and effective height Taylor 1958 Cabrol 1966 Yacoub 1983 Carpentier 1983 David 1992 David III 1996 De Paulis Izumoto 2002 Lansac 2007 Hopkins 2003 Gleason 2005 Hahm 2006 Kollar 2007 Need for standardization Schäfers 2009 Rankin 2011

3 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases Euro Heart J 2014 Nov 1;35(41):

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

Subcommissural plication stitches (Cabrol stitches 1966) Plicating U stitches at the base of the interleaflet triangles = partial subvalvular annuloplasty Plicating U stitches at the commissures =

5 Subcommissural plication stitches (Cabrol stitches 1966) Plicating U stitches at the base of the interleaflet triangles = partial subvalvular annuloplasty Plicating U stitches at the commissures = partial supravalvular annuloplasty 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 and tricuspid aortic valve repair failure Useful to protect a commissural repair or as a bailout technique De Kerchove EJCTS 2012 Aicher Circulation 2011

6 Aortic annuloplasty and valve sparing root replacement? Risk factor for failure of the Remodeling : Annulus dilation >25-28 mm Remodeling of the aortic root Annulus Ø 25 mm eh from 10.9 to 8.0 mm ch from 3.3 to 0.3 mm Reimplantation of the aortic valve - + Treatment of aortic annulus dilation Marom JTCVS 2012 Reimplantation performs a subvalvular annuloplasty Subvalvular annuloplasty increases ch Remodeling alone is a contraindication if annulus>25 mm Burkhart JHVD 2003 Lansac EJTCVS 2006 Hanke JTCVS 2009 David JTCVS 2010 Kunihara JTCVS 2011

7 Aortic root dynamics after valve sparing Remodeling of the aortic root Reimplantation of the aortic valve Reimplantation Remodeling Normal + Sinuses of Valsalva ± + Aortic Root expansibility (interleaflet triangles) - Leyh RG. Circulation 1999 Cusp motion and expansibility of the aortic root are best preserved 1) after Remodeling than after Reimplantation 2) with graft with neo- sinuses of Valsalva than without Remodeling provides the most physiological root reconstruction Ranga. ICVTS 2006 Furukawa. ATS 2004 Robiczek. Acta Chir Belg 2002 Grande allen. JTCVS 2000 Matsumori. ICVTS 2007 Aybeck. JHVD 2005 Markl. JTCVS 2005 Erasmi. JTCVS 2005 Kvitting. JTCVS 2004 Grande allen. JTCVS 2000 Robiczek. ACB 2002 De Paulis. ATS 2002 Furukawa. ATS 2004 Fries. JTCVS 2006 Ranga. ICVTS 2006 Katawama. JTCVS 2008 Erasmi. JTCVS 2005 Soncini. MEP 2009

8 Physiological and standardized approach to Valve Sparing Root Replacement + = Remodeling 1983 Yacoub Reimplantation 1992 David Remodeling + subvalvular annuloplasty

Reasons for valve sparing failures Cusp prolapse Remodeling / Reimplantation Reduction of the STJ eh : - 3 to - 4 mm Symmetrical prolaspse STJ No eh resupension (Eye balling repair) Schäfers et al.

9 Reasons for valve sparing failures Cusp prolapse Remodeling / Reimplantation Reduction of the STJ eh : - 3 to - 4 mm Symmetrical prolaspse STJ No eh resupension (Eye balling repair) Schäfers et al., JTCVS 2006 Risk factor for AI recurrence Reoperation Lansac JTCVS 2010 Soncini. MEP 2009 Bierbach EJTCVS 2010 Oka ATS 2011 Kunihara JTCVS 2011 Cusp eh resuspension Shresta EJTCVS 2011 Jeanmart ATS 2007 Marom JTCVS 2012 De Paulis 2010 Zacek with permission

10 1.Dissection of the subvalvular plane

11 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

12 3. 6 subvalvular «U» stitches

13 4. Aligment of cusp free edges prior Remodeling NC LC RC

14 5. Suture of the Remodeling

15 6. Cusp resuspension after the Remodeling (effective height 9 mm) ch eh Schäfers et al., JTCVS 2006

16 7. Subvalvular ring implantation

17 Pre and Post Remodeling with flexible Extra Aortic Ring Annuloplasty Pre-op Post-op

18 Root aneurysms: Bicuspid valves (Sinus Valsalva Ø 45 mm) 6 subvalvular «U» stitches Aligment of cusp free edges Commissures 2 symmetric neosinuses at 180 Effective height measurement Subvalvular aortic annuloplasty

Cusp resuspension (effective height 9 mm) Placement of

19 Isolated aortic insufficiency (all diameters 40 mm) 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 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 Supra-coronary graft Supra-valvular annuloplasty + subvalvular annuloplasty + subvalvular annuloplasty (annulus > 25 mm) Live on tape Video Cusp repair on caviaar.com Aortic valve repair: a step + by step approach Alignment of the cusp free edges Paris March 23-24th 2017 Resuspension of cusp effective caviaar.com height Subvalvular annuloplasty (annulus> 25 mm) Subvalvular external aortic annuloplasty

22 IMM serie : 232 patients 30 days mortality : 1.4% Mean Follow up 40.1±37.8 months ( ) Survival at 7 years 89.9% 90.5 % 97.5 % 100 % Freedom from reoperation at 7 years was similar among each phenotype with no difference between bicuspid and tricuspide valve No Valve related reoperation for bicuspid valve Lansac et al EJTCS in press

23 Remodeling + ring Since 2009 systematic cusp effective height assessment tended to improve freedom from reoperation up to 98.9% Freedom from reoperation at 7 years 90.5% Similar for tricuspid and Bicuspid freedom from AI 3 up to 100% Expansibility is preserved at the aortic annular base and SoV levels up to 19 months (1-64) Independently of age and bicuspid valve Freedom from AI grade 3 at 7 years 93.1% Freedom from AI grade 2 at 7 years 76.0%

24 Isolated AI repair+open aortic ring Single or double annuloplasty? No reoperation for bicuspid or tricuspid valve Additional ring at STJ level (double sub and supra-valvular annuloplasty) tend to reduce recurrent of AI when compared to single subvalvular annuloplasty

25 Open Prospective International Multicenter Registry Isolated AI and/or ascending aorta aneurysm Candidates for Aortic valve repair / sparing Surgical indication No Medical Registry (In process) Yes Surgical Registry Aortic valve Repair / sparing and Replacement Evaluation of the Guidelines Evaluation of the results Open to all center, Join us! AVIATOR@HeartValveSociety.org

Remodeling or Reimplantation?

Remodeling or Reimplantation? Emmanuel Lansac, Isabelle Di Centa Cardiac Surgery Institut Mutualiste Montsouris, Paris, France Aortic root dynamics after valve sparing Remodeling of the aortic root Reimplantation