aortic valve repair: when and how to employ this novel approach? · 2018. 8. 24. · aortic valve...
TRANSCRIPT
Aortic valve repair:
When and how to employ
this novel approach?
Konstadinos A Plestis, MD
System Chief of Cardiac Thoracic and Vascular Surgery
Main Line Health Care System
Professor Sidney Kimmel Medical College
Thomas Jefferson University
Aortic Valve
LANKENAU HEART INSTITUTE
Normal Aortic Valve
•Aortic cusps
•Aortic annulus
•Valsalva sinuses
•Commissures
•Sinotubular junction
LANKENAU HEART INSTITUTE
The functional aortic annulus (FAA)
LANKENAU HEART INSTITUTE
STJ
AVJ
Aortic Valve Regurgitation
Khourhy Classification
• Functional Annular dilatation: type 1
• Leaflet Prolapse: type 2
• Leaflet Restriction: type 3
LANKENAU HEART INSTITUTE
Mechanism of Aortic Regurgitation
ANNULAR DILATATION - Type 1
LANKENAU HEART INSTITUTE
STJ dilatation STJ+AVJ dilatation AVJ dilatation
Mechanism of Aortic Regurgitation
CUSP PROLAPSE – Type 2
LANKENAU HEART INSTITUTE
Aortic Valve Repair for Aortic Regurgitation
LANKENAU HEART INSTITUTE
Sino-tubular
Junction dilatation
Type Ia: Sinotubular dilatation
LANKENAU HEART INSTITUTE
Type Ib: Aortic root aneurysm
Aortic root
aneurysm
LANKENAU HEART INSTITUTE
Type Ib: Aortic root aneurysm
Aortic root
aneurysm
LANKENAU HEART INSTITUTE
Type Ib: Valsalva Sinus Aneurysm
Sinus of Valsalva
aneurysm
LANKENAU HEART INSTITUTE
Annular dilatation
Type 1c: Annular dilation
LANKENAU HEART INSTITUTE
Type Id: Cusp perforation
Cusp perforation
LANKENAU HEART INSTITUTE
Type Id: Cusp perforation
Leaflet perforation
LANKENAU HEART INSTITUTE
Type II: Flail aortic cusp
Cusp prolapse
LANKENAU HEART INSTITUTE
Cusp prolapse
Type II: Flail aortic cusp
LANKENAU HEART INSTITUTE
Type II: Partial cusp prolapse
Cusp prolapse
LANKENAU HEART INSTITUTE
Cusp prolapse
Type II: Partial cusp prolapse
LANKENAU HEART INSTITUTE
Cusp prolapse
Type II: Partial cusp prolapse
LANKENAU HEART INSTITUTE
Type III: Heavily calcified valve
Cusp restriction
LANKENAU HEART INSTITUTE
Cusp restriction
Type III: Heavily calcified valve
LANKENAU HEART INSTITUTE
Cusp restriction
Type III: Heavily calcified valve
LANKENAU HEART INSTITUTE
Anatomy of the Root
LANKENAU HEART INSTITUTE
Effective Height
LANKENAU HEART INSTITUTE
Schafers H.-J. et al.; J Thorac Cardiovasc Surg 2006;132:436-438
Effective Height
LANKENAU HEART INSTITUTE
Isolated leaflet prolapse
LANKENAU HEART INSTITUTE
Aortic Leaflet Plication
LANKENAU HEART INSTITUTE
Subcomissural annuloplasty
LANKENAU HEART INSTITUTE
Indications for Aortic Valve Repair
• Tricuspid or bicuspid aortic valves
• Aortic Valve Regurgitation
• Valve leaflets without calcification, fibrosis or multiple
fenestrations
• Root Aneurysm
• Selective endocarditis cases
LANKENAU HEART INSTITUTE
Bicuspid Aortic Valve Repair
LANKENAU HEART INSTITUTE
LANKENAU HEART INSTITUTE
LANKENAU HEART INSTITUTE
LANKENAU HEART INSTITUTE
Mini Sternotomy
LANKENAU HEART INSTITUTE
Mini Sternotomy
LANKENAU HEART INSTITUTE
Bicuspid Aortic Valve Repair
Ascending Aneurysm Replacement
LANKENAU HEART INSTITUTE
Case Presentation
Bicuspid Aortic Valve Repair - Extension
LANKENAU HEART INSTITUTE
31 yo female
•Asymptomatic
•Severe AI
•Bicuspid AV
•Ascending aortic aneurysm
LANKENAU HEART INSTITUTE
Bicuspid Aortic Valve Repair
Endocarditis
LANKENAU HEART INSTITUTE
32 yo male
•Endocarditis
•Bicuspid AV
•NCC perforation
•Severe AI
•Annular dilatation
LANKENAU HEART INSTITUTE
Aortic Valve Repair Outcomes
Outcomes
n=157
Age 59±15
Males 116 (74%)
LANKENAU HEART INSTITUTE
Aortic Valve Repair
Tricuspid AV 131 83%
Bicuspid AV 26 17%
Endocarditis 8 5%
LANKENAU HEART INSTITUTE
Concomitant Procedures
David procedure 23 15%
Total Arch Replacement 6 4%
Hemiarch 31 20%
MVR 9 6%
CABG 20 13%
LANKENAU HEART INSTITUTE
Complications
Mortality 2 1.2%
Stroke 4 2.5%
New RI 3 1.9%
PVS 22 14%
PVS-Prolonged Ventilatory Support
RI- Renal Insufficiency
LANKENAU HEART INSTITUTE
Bleeding 5 3%
Afib 35 22%
CHF 4 2%
CHF- Congestive Heart Failure
Complications
LANKENAU HEART INSTITUTE
Follow up
LANKENAU HEART INSTITUTE
Mean Follow up: 5 yrs
Freedom from AI > 2+ : 93%
Freedom from reoperation: 94%
Literature Review
LANKENAU HEART INSTITUTE
Aortic Valve Repair
El Khoury
2010
(n=122)
BAV
El Khoury
2012
(n=475)
Schafers
2010
(n=640)
Holubec
2014
(n=100)
Svensson
2014
(n=720)
Age 44 53 56 51 42
Male 92% 81% 73% 73% 87%
Acute Dissection N/A N/A 10% N/A N/A
BAV 100% 35% 32% 60% 100%
TAV 0% 65% 64% 40% 0%
AI
43% 34% 47% 82% 85%
Aortic Dilatation
14% 46% 39% 67% N/A
AI and Dilatation
43% 19% N/A N/A N/A
Aortic Valve Repair
El Khoury
2010
(n=122)
BAV
El Khoury
2012
(n=475)
Schafers
2010
(n=640)
Holubec
2014
(n=100)
Svensson
2014
(n=720)
Raphe Repair 80% N/A N/A N/A Yes
Cusp Prolapse
Repair 65% N/A 83% 70% Yes
Annuloplasty 42% 32%
N/A
47% Yes
Reimplantation 34% 41% 50% 12% N/A
Remodeling 10% 10%
N/A
44% N/A
LANKENAU HEART INSTITUTE
Aortic Valve Repair
El Khoury
2010
(n=122)
BAV
El Khoury
2012
(n=475)
Schafers
2010
(n=640)
Holubec
2014
(n=100)
Svensson
2014
(n=720)
Mortality 0% 0.8% 3.4% 0.8% 0.4%
Stroke 0.8% 1.1% N/A N/A 0.3%
LANKENAU HEART INSTITUTE
Aortic Valve Repair
El Khoury
2010
(n=122)
BAV
El Khoury
2012
(n=475)
Schafers
2010
(n=640)
Holubec
2014
(n=100)
Svensson
2014
(n=720)
1 year 98%
3 years 84%
5 years 94% 91% 87% 51%
10 years 85% 81%
Freedom from Moderate or Severe Aortic Insufficiency
LANKENAU HEART INSTITUTE
Aortic Valve Repair
El Khoury
2010
(n=122)
BAV
El Khoury
2012
(n=475)
Schafers
2010
(n=640)
Holubec
2014
(n=100)
Svensson
2014
(720)
1 year 98% 95%
5 years 94% 94% 93% 89% 87%
10 years 83%
86% 86% 87% 78%
15 years 64%
Freedom from Reoperation
LANKENAU HEART INSTITUTE
Aortic Valve Repair
El Khoury
2010
(n=122)
BAV
El Khoury
2012
(n=475)
Schafers
2010
(n=640)
Holubec
2014
(n=100)
Svensson
2014
(n=720)
1 year 99% 99%
5 years 93% 92% 94% 97%
10 years 73% 80% 94%
20 years 82%
Long Term Survival
LANKENAU HEART INSTITUTE
Conclusions
• Aortic valve repair has evolved significantly
• Results are reproducible
• 10 year outcomes are excellent
LANKENAU HEART INSTITUTE
Thank You
LANKENAU HEART INSTITUTE
Patch Repair
LANKENAU HEART INSTITUTE
Central Cusp Plication Technique
LANKENAU HEART INSTITUTE
Free Margin Resuspension
with 7/0 PTFE suture
LANKENAU HEART INSTITUTE
Minimally Invasive Procedure
• Excision of the vegetations of the conjoined leaflet
•Repair of perforation of NCC
• Free edge plication of conjoined leaflet
• Annuloplasty to 25 mm
Type II: Whole cusp prolapse
Cusp prolapse
LANKENAU HEART INSTITUTE
Cusp prolapse
Type II: Whole cusp prolapse
LANKENAU HEART INSTITUTE
Cusp prolapse
Type II: Whole cusp prolapse
LANKENAU HEART INSTITUTE
Case Presentation
Isolated Tricuspid Valve Repair
LANKENAU HEART INSTITUTE
45 yo male
• Increasing SOB
• Severe AI
• Rupture of fenestration
• Leaflet prolapse
Procedure
• Aortic valve repair
• Patch of the fenestration
• Free edge plication
• Subcomissural annuloplasty
• MV Repair
LANKENAU HEART INSTITUTE
LANKENAU HEART INSTITUTE
LANKENAU HEART INSTITUTE
LANKENAU HEART INSTITUTE
Case Presentation
AV repair, External Annuloplasty
61 yo male
• Increasing shortness of breath
LANKENAU HEART INSTITUTE
Preoperative Diagnosis
• Severe aortic valve regurgitation
• Bicuspid aortic valve
LANKENAU HEART INSTITUTE
Procedure
• Aortic valve repair
• Conjoined left and right leaflets
• Free edge plication
• Circumferential external annuloplasty
• Sinotubular junction fixation
LANKENAU HEART INSTITUTE
LANKENAU HEART INSTITUTE
LANKENAU HEART INSTITUTE
Comorbidities
Hypertension 118 75%
Diabetes 15 10%
COPD 21 13%
Renal Insufficiency 13 8%
Stroke 13 8%
LANKENAU HEART INSTITUTE
Aortic Valve Repair
Emergent 24 15%
Urgent 27 16%
Redo 10 6%
LANKENAU HEART INSTITUTE
Operative times
Pump time 169±56
Cross Clamp time 123±52
LANKENAU HEART INSTITUTE
PRBC 2.0±3.0
FFP 1.5±2.0
Platelets 1.4±2.2
Cryoprecipitate 1.5±3.6
Blood Utilization
LANKENAU HEART INSTITUTE
Aortic Valve Repair
El Khoury
2010
(n=122)
BAV
El Khoury
2012
(n=475)
Schafers
2010
(n=640)
Holubec
2014
(n=100)
Svensson
2014
(n=720)
CPB 106 114 N/A 115 66
CC 86
95 N/A 93 49
LANKENAU HEART INSTITUTE
Tricuspid Aortic Valve Repair
LANKENAU HEART INSTITUTE
LANKENAU HEART INSTITUTE