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Intraoperative Transesophageal Intraoperative Transesophageal Echocardiographic Predictors of Echocardiographic Predictors of
Recurrent Aortic Regurgitation after Recurrent Aortic Regurgitation after Aortic Valve RepairAortic Valve Repair
le Polainle Polain JB, JB, PouleurPouleur AC, AC, Vancraeynest DVancraeynest D, , Pasquet APasquet A, , Gerber BGerber B, , Vandijck M, Noirhomme P, El Khoury G, Vandijck M, Noirhomme P, El Khoury G, Vanoverschelde Vanoverschelde JLJL
Cliniques Universitaires Saint Luc, Brussels, BelgiumCliniques Universitaires Saint Luc, Brussels, Belgium
Université Catholique de LouvainUniversité Catholique de Louvain
Aim of the studyAim of the study
The present study examines the The present study examines the intraoperativeintraoperative echocardiographicechocardiographic
featuresfeatures associated with associated with "late failure""late failure" of aortic valve repair.of aortic valve repair.
Method: Study populationMethod: Study population
From 12/From 12/1995 1995 to 06/to 06/20072007 186 186 consecutive patients (51 women, mean age: 54-Yrs) consecutive patients (51 women, mean age: 54-Yrs)
-- Aortic valve repair for significant AR Aortic valve repair for significant AR -- With comprehensive pre-, intra- and follow-up With comprehensive pre-, intra- and follow-up echocardiographyechocardiography
122 pts122 pts (group A, 53- Yrs) with no AR (group A, 53- Yrs) with no AR
23 pts23 pts (group B, 50- Yrs) with > grade 1 AR (group B, 50- Yrs) with > grade 1 AR
41 pts41 pts (group C, 63- Yrs) with recurrent severe (group C, 63- Yrs) with recurrent severe ARAR
Compared for immediate post-operative TEE Compared for immediate post-operative TEE measurements.measurements.
Analysis of the cause of recurrence (group B & C).Analysis of the cause of recurrence (group B & C).
Method: TEE analysisMethod: TEE analysis Pre-operative and immediate postoperative TEE :Pre-operative and immediate postoperative TEE :
120 degree -LAX120 degree -LAX AnnulusAnnulus
SinusesSinuses
ST junctionST junction
Tubular aortaTubular aorta Height of the sinusesHeight of the sinuses
Coaptation lengthCoaptation length
Symmetry of the coaptationSymmetry of the coaptation
Tips to annulusTips to annulus
Cusp’s belly to annulusCusp’s belly to annulus Eccentric JetEccentric Jet
Vena contracta wideVena contracta wide
Results (1): Follow-up:Results (1): Follow-up:
Mean Follow-up :Mean Follow-up : 24 24 monthsmonths41 41 pts had recurrent pts had recurrent severe ARsevere AR2323 needed a needed a REDOREDO
F-up TEEF-up TEE identified the cause of repair failure as identified the cause of repair failure as
Cusp prolapse: 26 pts Cusp prolapse: 26 pts
Restrictive cusp motion: 9 ptsRestrictive cusp motion: 9 pts
Rupture of a pericardial patch : 3 ptsRupture of a pericardial patch : 3 pts
Aortic dissection : 2 pts Aortic dissection : 2 pts
Endocarditis : 1 ptEndocarditis : 1 pt
Results (2): Pre-operative Results (2): Pre-operative characteristicscharacteristics
Before surgeryBefore surgery Group AGroup A
(n=112)(n=112)Group B Group B (n=23)(n=23)
Group CGroup C
(n=41)(n=41)P valueP value
Bicuspid (%)Bicuspid (%) 40 17 37 0.12
Marfan (%)Marfan (%) 0 9 15 <0.001
Restrictive AR (%)Restrictive AR (%) 13 43 46 <0.001
Annulus (mm)Annulus (mm) 25 ± 4 24 ± 4 26 ± 6 0.27
Sinus (mm)Sinus (mm) 40 ± 8 39 ± 9 41 ± 13 0.61
ST jct° (mm)ST jct° (mm) 35 ± 9 35 ± 9 34 ± 9 0.93
Tubular Ao (mm)Tubular Ao (mm) 42 ± 11 39 ± 8 37 ± 13 0.14
Results (3): immediate post-op TEE:Results (3): immediate post-op TEE:
After surgeryAfter surgery Group AGroup A
(n=112)(n=112)Group B Group B (n=23)(n=23)
Group CGroup C
(n=41)(n=41)P value P value
Coapt. Length Coapt. Length (mm)(mm)
6.6 ± 2.8 3.2 ± 1.4 2.2 ± 1.6 <0.00
1
Tips - annulus Tips - annulus (mm)(mm)
6.9 ± 4.3 3.0 ± 3.1 0.1 ± 4.2 <0.00
1
Cusp - annulus Cusp - annulus (mm)(mm)
-1.2 ± 2.8 -1.5 ± 3.2 - 3.9 ± 4.8 <0.00
1
Vena contracta Vena contracta (mm)(mm)
0.1 ± 1.1 2.4 ± 1.7 2.6 ± 1.4<0.00
1
Eccentric Jet (%)Eccentric Jet (%) 9 30 73<0.00
1
Annulus (mm)Annulus (mm) 21 ± 4 21 ± 4 26 ± 4<0.00
1
Sinus (mm)Sinus (mm) 29 ± 5 30 ± 5 31 ± 5 0.04
ST jct° (mm)ST jct° (mm) 26 ± 4 24 ± 4 27 ± 4 <0.01
Results (4):Results (4): Cox univariate analysis Cox univariate analysisPreoperative Preoperative Type 3 ARMarfan disease
PostoperativePostoperativeThe coaptation lengthThe degree of cusp billowingThe level of coaptation (relative to the annulus)The diameter of the aortic annulusThe diameter sino-tubular junctionThe presence of a residual ARThe severity of residual AR (vena contracta width)
Were found to correlates with AR failure
Results (4):Results (4): Cox multivariate analysis Cox multivariate analysis
Multivariate Multivariate analysisanalysis
HRHR IC 95% exp IC 95% exp ββ
P P valuevalue
Coapt. LengthCoapt. Length 0.820.82 [[0.63 – 0.63 – 1.001.00 ] ]
=0.05=0.05
Tips below the Tips below the annulusannulus 7.907.90 [6.52 - 9.28][6.52 - 9.28] <0.01<0.01
Residual ARResidual AR 5.305.30 [[1.47 - 1.47 - 6.576.57 ] ]
=0.01=0.01
Aortic annulusAortic annulus 1.181.18 [[1.03 - 1.03 - 2.452.45 ] ]
=0.01=0.01
Independent predictors of late AR recurrenceIndependent predictors of late AR recurrence
TEE decision chartTEE decision chart
Coaptation tips below the annulus?
No
Residual AR?
Yes
Reccurence rate: 20/28 (71%)Redo: 12/28 (43%)
No
Reccurence rate: 2/81 (2%)Redo: 1/81 (1%)
Yes
Coaptation length?
CL < 4mm
Reccurence rate: 17/36 (47%)Redo: 10/36 (28%)
CL > 4mm
Reccurence rate: 2/41 (5%)Redo: 0/41 (0%)
4-years Survival free from redo 4-years Survival free from redo
according to TEEaccording to TEE
Time (Years)0 1 2 3 4
Eve
nt F
ree
Sur
viva
l
0,0
0,2
0,4
0,6
0,8
1,0
Tips < annulus
Tips > annulus Residual AR CL < 4mm
Tips > annulus No Residual AR
Tips > annulus Residual AR CL > 4mm
Log rank p < 0.001
Example pre and immediate post Example pre and immediate post operative TEE operative TEE
of patient with late failureof patient with late failure
Pre-op TEE:Pre-op TEE: Post-op TEE Post-op TEE::
Conclusion:Conclusion:
Our results demonstrate that Our results demonstrate that intraoperative TEE can be used to intraoperative TEE can be used to
identify pts undergoing AR repair who identify pts undergoing AR repair who are at increased risk for late repair are at increased risk for late repair
failurefailure