why i trust av reimplantation - aortic live congress 2020 · 2018. 11. 1. · de paulis et al. 2016...
TRANSCRIPT
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5th Aortic Live Symposium
WHY I TRUST AV REIMPLANTATION
Ruggero De Paulis European Hospital Rome, Italy
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Disclosure
2
Speaker name:
Ruggero De Paulis
I have the following potential conflicts of interest to report:
Consulting
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
X I receive royalties from Terumo Aortic
I do not have any potential conflict of interest
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I trust AV reimplantation because is:
1. a SAFE procedure that...
2. provide an optimal ANATOMICAL RECONSTRUCTION,
3. an excellent restoration of NORMAL ROOT and LEAFLET PHYSIOLOGY and
4. STABLE long-term results in
5. a REPRODUCIBLE and STANDARDIZED fashion
3
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1. A safe procedure. Technical point of view
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1. A safe procedure. Operative mortality
Authors Patents Mortality
Kallenbach et al. 2005 284 3.2%
David et al. 2007 289 1.7%
De Paulis et al. 2016 124 (203) 1.6% (0.9%)
Miller et al. 2012 233 0,9%
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1. A safe procedure. Metanalysis
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Valve sparing operation (David I)theoretic problems
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Modifications of straight grafts for a better root reconstruction
Uni-graft Cardioroot
Valsalva graft
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The ability of the graft to precisely
repositioning of the commissures
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Immediate postop. After a month
Empty space between Dacron and commissures
Evidence of a trifoliate aspect of the root
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Impossibility to do the same
with a larger straight graft
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Comparable with remodeling
Remodeling Reimplantation
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2. Optimal anatomical reconstruction
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4D MRI flow comparison of
reimplantation with
Straight graft, Valsalva graft, and
controls
JTCVS 2018, in press
3. Restoration of root and leaflet physiology
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4D MRI rotational flow of
reimplantation with
Straight graft, Valsalva graft, or
controls
JTCVS 2018, in press
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Wall stress measured in the descending aorta
JTCVS 2018, in press
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16 years after reimplantationfor acute dissection
3. Restoration of root and leaflet physiology
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TABLE 1. Preoperative data: clinical and echocardiographic characteristics of patients
No. of patients 203
Age (mean)(y)
53 ± 13
Male gender 176 (86,69%)
Associated diseases
Marfan syndrome 25 (12,3%)
Loeys-Dietz syndrome 1 (0,5%)
Type A aortic dissection 10 (5%)
Bicuspid aortic valve 33 (16,2%)
Previous cardiac surgery 3 (1,47%)
Preoperative echocardiographic findings
Aortic regurgitation
• ≤ 2+ 141 (69,45%)
• ≥ 3+ 62 (30,54%)
Annulus (mm ± SD) 25 ± 2,7
Valsalva sinus (mm ± SD) 50 ± 4
STJ (mm ± SD) 44 ± 5,7
Ascending aorta (mm ± SD) 47 ± 7,2
Patient population
4. Stable long-term results
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TABLE 2. Operative data
Mean Dacron graft diameter 30,58 ± 1,3
Leaftlet repair 68 (33,5%)
Mean cardiopulmonary bypass time ± SD (min) 123 ± 26
Mean aortic crossclamp time ± SD (min) 105 ± 18
Circulatory arrest (No pts) 8 (3,94%)
Number of sub-valvular annular stitches
• BAV pts 8 ± 0,9
• TAV pts 6 ± 0,87
Operative data
4. Stable long-term results
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Overall Survival
75.4 ± 7.7%@18 yrs
15 deaths
1 HF
14 non cardiac
related
4. Stable long-term results
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Freedom from Reoperation
92.9 ± 2.98%@18 yrs
4. Stable long-term results
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Freedom from Aortic Regurgitation (not reoperated)
96 ± 1.85%@18 yrs
4. Stable long-term results
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Freedom from Endocarditis
98.9 ± 0.7%@18 yrs
4. Stable long-term results
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Freedom from Thromboembolic event
97.1 ± 2.4%@18 yrs
4. Stable long-term results
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Learning curve effect (reoperation)
81%
100%100%
First 5 years
5 to 10 years
> 10 years
4. Stable long-term results
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Learning curve effect (residual AR)
81%
94%92%
First 5 years
5 to 10 years
> 10 years
4. Stable long-term results
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Freedom from Reoperation (BAVs vs. TAVs)
TAV 92%
BAV 100%
4. Stable long-term results
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Freedom from Aortic Regurgitation (BAVs vs. TAVs)
TAV 89%
BAV 91%
4. Stable long-term results
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77% @18yrs
Long-term results in the literature
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94% at 18yrs 78% at 18yrs
Long-term results in the literature
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77%
54%
Long-term results in the literature
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80%
67%
Long-term results in the literature
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77%
Long-term results in the literature
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11%
48%
Long-term results in the literature
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Long-term results in the literature
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93%
Long-term results in the literature
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92%
Long-term results in the literature
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Why I trust reimplantation
1. It is a significantly very hemostatic procedure
1. It is performed in a standard and reproducible fashion
1. It allows to observe and maintain good geometry while
suturing
1. It provides a complete annular and root support (behind the
commissure is particularly useful in case of acute
dissection)
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4. When approaching 20 years of follow-up the resultsappear to be stable
5. Non invasive assessment of aortic flow reveal a re-established root anatomy and physiology
6. Resistence to endocarditis and thromboembolism isstriking
7. Improvements in the ability of leaflets plasty are broadening the indications
Why I trust reimplantation
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Aortic Live @ Essen 2018