Aortic Valve Repair Introduction · Aortic Valve Repair – Introduction H.-J. Schäfers Dept. of...

Aortic Valve Repair –Introduction

H.-J. Schäfers

Dept. of Thoracic and Cardiovascular Surgery

Saarland University Medical Center

Homburg/Saar, Germany

18.09.2019

Leonardo da Vinci:

Trattato della Pittura (da Vinci)/Parte seconda/77. Dell'errore di quelli che usano la pratica senza la scienza

«Sempre la pratica dev’essere edificata sopra la buona teorica, della quale la prospettiva è guida e porta, e senza questa nulla si fa bene.»

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“Practice should always be based upon a sound knowledge of theory.

Without this guidance and door nothing will be done well”

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Aortic Valve - Historic Repair Attempts

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Aortic Valve Replacement

Late complications:

Thromboembolism

Anticoagulation/Hemorrhage

Structural failure

PV endocarditis

Reproducible

Low Mortality

(curr. 2-4%)

Mortality

VR complications

Reoperation

Survival

Mohty D, Curr. Card. 2002

Repair vs. Replacement (Mitral)

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Root Repair – Technical Options

(Yacoub 1993)(David 1992)(Frater 1986)

(Sinus < 45 mm)

Reimplantation

of Aortic ValveRoot RemodelingST Junction

Remodelling

(Cabrol 1966)

Subcommissural

Plication

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Aortic Valve Repair

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Aortic Valve Repair

All cusp margins should be at equal height for competent valve function.

Coaptation height should be high for secure diastolic function.

Cusp configuration should be maintained under systemic pressure.

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Duran CMG, J Card SurgDe Kerchove L, Eur J Cardiothorac

2018

15

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Aortic Valve Repair

Freedom from AI ≥ I

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Reimplantation Remodeling

2 l/min

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CE = π × [3/2×(a+b) - √a×b]

a

b ≈ raorta

a ≈ rcusprcusp ≈ 1 / raorta

Reduction of STJ and Cusp Prolapse

b

a‘b‘

RNC L

Functional Aortic Annulus / Basal Ring

Lansac E et al. ATS 2015

AV junction

Muscle inside

the sinus

Basal ring

De Kerchove et al, EJCTS 2018

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Aortic Valve Repair - Difficulties

Dimensions- of aortic root/(ring)

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Aortic Valve Repair - Difficulties

Vision from outflow

Configuration/coaptation of cusps

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Aortic Valve Repair - Difficulties

Geometry altered by

non-pressurized state

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Solutions

Geometry altered by non-pressurized state!

Stay sutures!

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Aortic Valve Repair - Assessment

Solutions

Configuration/coaptation of cusps

Swanson, Circ Res 1974

?effective height

1cm

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Effective Height effective height

1cm

Aortic Valve Repair

AUC = 0.94

0 10 20 30 40 50 60 70 80 90 100

0

10

20

30

40

50

60

70

80

90

100Sensitivity%

100% - Specificity%

Se

ns

itiv

ity

%

Hypothesis: eH ≥ 9mm = predictor of near-normal av function

497 patients with eH ≥ 9mm

No / trivial AR: 235 patients

Mild AR : 186 patients

Moderate AR: 2 patients

Receiver Operating Characteristic

Curve

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Higher effective height leads to improved coaptation height

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Configuration/coaptation of cusps

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Aortic Valve Repair - Assessment

TAV: 18-22 mm

BAV: 20-25 mm

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Causes of Cusp Pathology

• Prolapse n=606/826 =73%

(right > non > left-coronary cusp)

• Congenital malformation

• bicuspid n=276

• unicuspid n =50

• quadricuspid n =3

• Retraction / Calcium n=42Prolapse

Congenital

Retraction

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Aortic Valve – Stress Distribution

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Reconstructive Techniques

Plication of

Cusp Margin

Prolapse

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Reconstructive Techniques

Triangular

Resection

Fibrosis,

Calcium,

Redundancy

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Reconstructive Techniques

Stabilisation of

cusp (pericardium)

Fenestration

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Incidence of valve-

related complications

Hammermeister et al, JACC 2000

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Annular dilatation effects coaptation

Freedom from Reoperation

Root Repair – Technical Options

(Cabrol 1966)

Subcommissural

Plication

?

Annular Stabilisation

(> 27mm)

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Aortic Valve Reconstruction

• AV reconstruction is on its way to a rational and reproducible procedure based on geometricprinciples (A + B + C + ? = functioning AV)

• Scientific basis is becoming clearer

• Valve-related complications are rare if repair is stable

• Durability of repair is better than that of bioprostheses in young patients

• The need for patch repair of cusps is associated with limited durability

• AV reconstruction should be considered in every patient with AR

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Thank you for your attention