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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
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
