Remodeling or Reimplantation?

Transcription

1 Remodeling or Reimplantation? Emmanuel Lansac, Isabelle Di Centa Cardiac Surgery Institut Mutualiste Montsouris, Paris, France

2 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

3 Valve sparing procedures Remodeling of the aortic root Yacoub 1983 Reimplantation of the aortic valve David Treatment of STJ dilation + + Sinuses of Valsalva ± + Aortic Root expansibility (interleaflet triangles) - Supravalvular annuloplasty - Treatment of aortic annular base dilation + Sub and supravalvular annuloplasty

4 Aortic valve dynamics after valve sparing Reimplantation Remodeling Controls Leyh RG. Circulation 1999 Fries. JTCVS 2006 Cusp motion and expansibility of the aortic root is best preserved 1) after Remodeling than after Reimplantation De Paulis. ATS ) with graft with neo- sinuses of Valsalva than without 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

5 Valve sparing : reasons for failure Post-operative residual AI ± Pre op degree of AI ± cusp repair Pericardial patch eh<9 mm Risk factor for failure of the Remodeling : Annulus dilation >25-28 mm Main lesion at reoperation: Cusp prolapse Burkhart SHVD 2003 Lansac EJTCVS 2006 Jeanmart ATS 2007 Hanke JTCVS 2009 De Paulis 2010 David JTCVS 2010 Shresta EJTCVS 2011 Oka ATS 2011 Kunihara JTCVS 2011

6 Influence of valve sparing procedure on cusp coaptation? z [mm] Reduction of STJ 16 lowers coaptation 14 level towards 12aortic annular base Soncini. MEP 2009, Pr C. Antona, with permission systole open valve Nodulus of Arantius height time [s] Physiological Reimplantation Remodelling diastole closed valve Resuspension of the cusp effective Induces symmetrical prolapse Reimplantation 3.8 mm Remodeling 3.3 mm Schäfers et al JTCVS 2006

7 Goals for aortic valve repair Treat annular base and STJ dilated Ø Preserve root dynamics (neosinus of Valsalva) Preserve root expansibility (interleaflet triangles) Restore cusp effective height Cochran 1995 David III 1996 Van Son 1999 Thubrikar 2001 De Paulis Hopkins 2003 Demers 2004 Gleason 2005 Hess 2005 Maselli 2006 Kollar 2007 Hetzer 2008 Ruvuolo 2009 Sievers 2010 Need for standardization

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

9 1.Dissection of the subvalvular plane

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

11 2. 6 subvalvular «U» stitches 6 6

12 3. Inspection of valvular lesions Aligment of cusp free edges prior Remodeling NC LC RC

13 4. Suture of the Remodeling

14 5. Cusp resuspension after the Remodeling (effective height 8 mm) ch eh Schäfers et al., JTCVS 2006

15 6. Subvalvular ring implantation

16 Bicuspid root aneurysms 6 subvalvular «U» stitches Aligment of cusp free edges Commissures 2 symmetric neosinuses at 180 Effective height measurement Subvalvular aortic annuloplasty

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18 Aortic valve repair using an external aortic ring 482 patients in 34 centers Preliminary trial 187 patients CAVIAAR Trial 130 valve repair versus 130 Bentall In process for analysis and 10 years follow-up 165 patients Prospective ongoing inclusion CAVIAAR Registry

19 24 surgeons - 14 centres 187 patients with Remodeling + External subvalvular aortic ring annuloplasty Eye Balling Alignment of cusp free edges Measurement of cusp effective height N AI 2 16 (25.0%) 9 (15.0%) 0 (0.0%) Pre-op annulus Ø 28 (26 28) 26 (25 28) 28 (26 29) 1 year Cusp repair Reoperation 2 (3.1%) 1 (1.7%) 0 (0.0%) follow-up 15 (20.3%) 19 (30.6%) 36 (70.6%) * Composite 18 Residual AI 2 6 (28.1%) (8.1%) 8 9 (12.9%) (15.0%) 0 (0.0%) 1 (1.9%) * outcome Medium Re-repair FU (38-67) (19-31) (4-14) Last Conversion AI grade II 17.6% (13) 14.5% (9) 0 (0.0%) follow-up Post-op annulus Ø % (19 21) diameter, 20 (19 gradient 21) 5.2±2.320 mmhg (19 21) 1 endocarditis Cusp prolapse 1 endocarditis Cusp prolapse Reoperation 8.1% (6) 4.8% (3) 0 (0.0%) Risk factors for AI recurrence «Eye Balling» Residual AI Tricuspid valve Lansac et al. JTCVS 2010

20 Remodeling + annuloplasty: advantages over Reimplantation? Moving from valve sparing to aortic valve repair Physiological root reconstruction Resuspension of cusp effective height + + Subvalvular aortic annuloplasty

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 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 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