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 annuloplasty 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 annuloplasty 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 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 aortic valve repair failure Useful to protect a commissural repair or as a bailout technique De Kerchove EJCTS 2012 Aicher Circulation 2011

5 Aortic annuloplasty 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 annuloplasty 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 David

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 annuloplasty Need for standardization

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

9 Phenotypes of the ascending aorta Aortic root aneurysm Supra-coronary aneurysm Isolated AI Valsalva 45 mm Valsalva<40 mm Valsalva<40 mm STJ>45 mm STJ<40 mm Standardized and physiological approach to aortic valve repair Root reconstruction Remodeling + sub-valvular annuloplasty Supra-coronary graft + sub-valvular annuloplasty (annulus > 25 mm) Subvalvular annuloplasty Cusp repair + Resuspension of cusp effective height Subvalvular aortic annuloplasty

10 What is the aortic annulus? From Anderson R. with permission

11 NC Sinus Non coronary leaflet RC 2.02 ± ±1.28 L At.

12 L-NC commissure Non coronary-left commissure ±1.71 L. At NC leaflet 1.57 ±0.44 Mit V.

13 L leaflet Left coronary leaflet ± ±0.81

14 R C L C Left-right commissure LC leaflet ±2.61 LDA 3.25 ±0.81 First septal artery

15 Right coronary leaflet Tric V. Tric V. Pul. V Pul. V ±1.79 R Vent RC leaflet 3.34 ±1.12

16 Right-Non coronary commissure ±1.18 L At Mit V R At Tric V 2.10 ±0.52

17 +2.35 ± ± ± ± ± ± ±2.61

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

19 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

28-30 31-33 34-39 40 26 28 30 32 34 Extra aortic ring Ø

20 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

21 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 annuloplasty Supra-coronary graft + subvalvular annuloplasty (annulus > 25 mm) Cusp repair Subvalvular annuloplasty (annulus> 25 mm) + Alignment of the cusp free edges Resuspension of cusp effective height Subvalvular external aortic annuloplasty

22 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

25 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

Root phenotype Root aneurysm Valsalva 45 mm

28 Root phenotype Root aneurysm Valsalva 45 mm Supra coronary aneurysm Valsalva 40 mm Cusp motion Isolated AI All Ø 40 mm Normal (I) Prolaps (II) Retracted (III) AI zero Central jet Eccentric jet Carpentier A. JTCVS 1983, El Khoury et al curr opin cardiol 2005, Lansac et al EJCTS 2008

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

29 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 annuloplasty Supra-coronary graft + subvalvular annuloplasty (annulus > 25 mm) Cusp repair Subvalvular annuloplasty (annulus> 25 mm) + Alignment of the cusp free edges Resuspension of cusp effective height Subvalvular external aortic annuloplasty

International Multicenter Registry AI 2 and/or ascending aorta aneurysm Isolated AI Root aneurysms Supracoronary aneurysm Medical Registry Surgical

30 International Multicenter Registry AI 2 and/or ascending aorta aneurysm Isolated AI Root aneurysms Supracoronary aneurysm Medical Registry Surgical Registry Aortic valve Repair and Replacement Informed consent Join Study start date: us now! Yearly follow-up aviator.registry@orange.fr

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