Remodeling or Reimplantation?

Transcription

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

2 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

3 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 + Treatment of STJ dilation Treatment of aortic annular base dilation Reimplantation of the aortic valve Reimplantation performs a subvalvular annuloplasty Marom JTCVS 2012 Remodeling alone Subvalvular is a contraindication annuloplasty increases if ch annulus>25 mm Burkhart JHVD 2003 Lansac EJTCVS 2006 Hanke JTCVS 2009 David JTCVS 2010 Kunihara JTCVS 2011

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

5 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) 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

6 Remodeling + annuloplasty: advantages over Reimplantation? Reimplantation Remodeling + Ring Selected cases (AI Grade II) 1) Annuloplasty 1) Root 6% of high risk patients 20 % of low risk patients 2) Root STS Database, EACTS ) Leaflets (eh caliper) Eye Balling valve repair 3) Leaflets 3) Annuloplasty ACS 2013

7 1. Dissection of the subvalvular plan

8 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

9 2. Inspection of cusp lesions Geometric height Retracted if <16 mm in tricuspid and <19 mm in bicupid Schäfers et al., JTCVS 2013

10 3. 6 subvalvular «U» stitches

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

12 5. Suture of the Remodeling

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

14 7. Subvalvular ring implantation

15 700 Aortic valve repair using an external aortic ring Preliminary trial 187 patients CAVIAAR Trial Risk factors for failure Operative mortality 2% 97% freedom AI 2 at 2 y 9 reop at 2 y mean FU Absence of eh resuspension 130 valve repair versus 131 CVG 30 days mortality 3.8% in each group Despite longer crossclamp times and a learning curve in the REPAIR group, there is no increase in post operative morbi-mortality compared to CVG group At 30 days, REPAIR group showed a trend towards reduce Major Adverse Valve Related Events compared to CVG group (3.8% versus 9.2%, p<0.08) Root dynamics study (60 pts) Expansibility is preserved at the aortic annular base and SoV levels up to 19 months (1-64) Independently of age and bicuspid valve

16 Moving from Valve Sparing to a standardized approach of Aortic valve REPAIR Physiological root Remodeling Resuspension of cusp effective height + + Expansible aortic annuloplasty

17 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 Supra-valvular annuloplasty (STJ> 35 mm) Subvalvular annuloplasty (annulus> 25 mm) + Alignment of the cusp free edges Resuspension of cusp effective height Subvalvular external aortic annuloplasty

18 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 Study started, join us! aviator@shvd.org