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Repair for Aortic Regurgitation:is it durable ?
Gébrine El Khoury
Cliniques Universitaires St-Luc, IREC, UCL, Brussels, Belgium
AATS 95th Annual Meeting
25-29 April, Seattle
Aorrtic valve repairthe basics
• -role of the functional aortic annulus:FAAdilation
• -role of the free margin of the leaflets:FMelongation
Yacoub David
• First « basic »:
Despite of normal leaflets, root aneurysms (FAA
Dilation) may induce aortic regurgitation, and
the restoration or recreation of normal root
(FAA) corrects the regurgitation.
Concept:
LESION DYSFUNCTION
TREAT THE LESION, CORRECT THE DYSFUNCTION
Aorrtic valve repairthe basics
Leaflet prolapse:excess length of free margin, shortening (plication) correct prolapse and AR
Leaflet prolapse: excess length of free margin
shortening (plication) of the free margin correct prolapse and AR
-Second « basic »:
Aorrtic valve repairthe basics
• -third « basic »
-Close relationship betweec FAA and FM
leaflet coaptation and MOTION
-close relationship between FAA and AR
FAA dilation AR
Aorrtic valve repairthe basics
Understanding Valve Dysfunction
Echocardiographic
Assessement
Classification
Surgical
Assessement
STJ – Sino-tubular Junction; SCA – Sub-Commissural Annuloplasty
JTCVS 2009;137:286-94Dysfunction etiology lesion repair
Classification of Dysfunctions
Functional classification of aortic regurgitationMechanism of AV dysfunction
Type 1 AR : FAA dilatation
Type 1a
(STJ)
Type 1b
(STJ+VAJ)
Type 1c
(VAJ)
Cusp perforation (Type 1d)
AV repair for AI: Mechanisms of AI
Cusp prolapse (Type 2)
AV repair for AI: Mechanisms of AI
Restricted cusp motion (Type 3)
AV repair for AI: Mechanisms of AI
Fundamental Principlesof Valve Repair
- Preserve or restore normal motion
- Create a large surface of coaptation
- Remodel and stabilize the annulusClose functional
relationship(functional unit)
Leaflets
Determinants of durabilty:
• Quality &quantity of tissue, patient selection
• Appropriate surgical technique - Excellent immediate result of repair
Leaflet coaptation,motion FAA stabilisationLong term durability
Valve repair and durability
A. Quality & quantity of tissue, patient selection
B. Appropriate surgical technique
AV repair for AI: Determinant of durability
- Moncuspid
- Bicuspid
- Quadricuspid
- Connective tissue disorders (Marfan, Loeys-Dietz, Ehler-Danlos, Familial Aneurysmal disease, …)
Congenital
AV repair for AI: Etiology
- Degenerative cusp
- Degenerative aorticaneurysm
(Atherosclerosis)
- Traumatic
- Infectious
- Acute aortic dissection
Acquired
AV repair for AI: Etiology
- Ross repair
- Re-repair
Redo
AV repair for AI: Etiology
Determinants of durabilty:
• Quality &quantity of tissue, patient selection
• Appropriate surgical technique - Excellent immediate result of repair
Leaflet coaptation,motion FAA stabilisationLong term durability
Valve repair and durability
AV repair for AI: Actual requirementOptimal coaptation + Stabilisation
Pethig K. ATS 2002le Polain de Waroux JB. JACC Card. Im. 2009
Bierbach BO. EJCTS 2010Aicher D. Circ. 2011
De Kerchove L. JTCVS 2011
• Effective height (eH) ≥ 9 mm
• Coaptation length ≥ 4 mm
• Circumferential annuloplasty
VAJ >26 mm
• No residual AR
A. Quality & quantity of tissue, patient selection
B. Appropriate surgical technique
AV repair for AI: Determinant of durability
El Khoury G. Cur. Op. Card. 2005
AV repair for AI: Mecanisms of AI
Supracoronary Ascending Aortic Aneurysms (Type 1A)
Freedom from AV Reoperation
0 24 48 72 960
20
40
60
80
100
No. at risk 55 41 28 10 3
Months
Fre
ed
om
fro
m A
V R
eo
pera
tio
n
97%
95%
95%
Freedom from Reop
AV repair for AI: Root dilatation (Type 1b) - VSRR
T. David JTCVS 2014
78%
93%
91%
Freedom from AR ≥2+
No predictors of recurrent AR
• Toronto: 1988 – 2010, 371 pts, 9% BAV, 50% cusp repair
• Homburg: 1995 – 2009, 430 pts, 30% BAV, 73% cusp repair
T. Kunihara JTCVS 2012
Freedom from AR ≥2+
AV repair for AI: Root dilatation (Type 1b) - VSRR
Freedom from AV reop.
• Brussels: 1996 – 2014, 275 pts, 43% BAV, 70% cusp repair
S. Mastrobuoni STSA 61st meeting 2014
100%92%
AV repair for AI: Root dilatation (Type 1b) - VSRR
AV repair for AI: Root dilatation (Type 1b)
in Marfan syndrome
T. David, JTCVS 2009
Freedom from AR >2+Freedom from AV reoperation
• Toronto: 1988 – 2006, 103 pts, mean age 37 y
vssr+cusp repair
AV Repair for AI: VSRR +/- Cusp repair
H.J. Schäfers Ann Thor Surg 2002 L. de Kerchove Circulation 2009
AV Repair for AI: Results Prolapse repair (Type 2)
M. Boodhwani, JTCVS 2011
93%
93%
87%
Tricuspidisation and
3 cusps extension
Sharma V. JTCVS 2014
Risk factors of reop: Severe preop AR, > mild AR at discharge
79% 72%75% 58%
• Mayo: 1986 – 2011, 331 pts, 40% BAV, 100% cusp repair
AV repair for AI: Isolated AICusp prolapse/restriction/perforation (Type 2,3, 1d)
AV repair for AI: Predictor of recurrent AICusp restriction (Type 3)
M. Boodhwani, JTCVS 2009
Freedom from AR >2+Freedom from AV reoperation
(Prolapse)(Restriction)
(Prolapse)(Restriction)
• Cusp Height to define cusp restrictionTAV < 16 mmBAV < 19 mm Schafers H.J. JTCVS 2013
AV repair for AI: Predictor of recurrent AICusp extension/restoration with Patch
Aicher D. Circ. 2011 Boodhwani M. JTCVS 2010
AV Leaflet Repair: ResultsLeaflet repair with patch
Mozala Nezhad Z. EJCTS 2014
Determinants of durabilty:
• Quality &quantity of tissue, patient selection
• Appropriate surgical technique - Excellent immediate result of repair
Leaflet coaptation,motion FAA stabilisationLong term durability
Valve repair and durability
AV repair for AI: Predictor of recurrent AICoaptation length and height
le Polain JB. JACC Card. Im. 2009
Tips < annulus
Tips > annulusResidual ARCoapt < 4 mm
Residual AR, Coapt >4 mm
Tips > annulus, No AR
AV repair for AI: Predictor of recurrent AICoaptation length and height
Aicher D. Circ. 2011
Determinants of durabilty:
• Quality &quantity of tissue, patient selection
• Appropriate surgical technique - Excellent immediate result of repair
Leaflet coaptation,motion FAA stabilisationLong term durability
Valve repair and durability
Aicher D. Circ. 2011
AV repair for AI: Predictor of recurrent AILarge ventriculo-aortic junction
T. Kunihara JTCVS 2012
BAV repair Remodeling
No circumferential annuloplasty
de Kerchove EJCTS 2015
AV repair for AI: Predictor of recurrent AILarge ventriculo-aortic junction
Navarra E. EJCTS 2013
Non-circumferential Subcommis. Annuloplasty (Cabrol stitch)
TAV repairBAV repair
AV repair for AI: Predictor of recurrent AILarge ventriculo-aortic junction
B
0 2 4 6 8 100
20
40
60
80
100
VSR VAJ 28mm
VSR VAJ 28mm
p=0.38
Years
%
Pts at riskVAJ 27 88 52 35 18 8 2VAJ >27 56 44 33 18 9 6
A
0 2 4 6 8 100
20
40
60
80
100
SCA VAJ 28mm
SCA VAJ 28mm
p=0.0001
Years
%
Pts at riskVAJ 27 117 92 61 44 23 7VAJ >27 18 13 8 1
De Kerchove L. EJCTS 2015
Circumferential annuloplasty in VS Reimplantion
AV repair for AI: Predictor of recurrent AILarge ventriculo-aortic junction
De Kerchove L. JTCVS 2011
0 12 24 36 48 60 72 84 960
20
40
60
80
100
6 years
64±15%
95±5%Group 2
p=0.0006
No. at risk
Group 1 53 42 33 27 21 18 15 10 8
Group 2 53 39 29 23 20 14 9 6 2
Group 1
Months
%
SCA
VSR
Matched comparison VSR vs SCA
Freedom from AR>1+
AV Leaflet Repair: Conclusions
• The mechanism of AR are actually well understood and the use of a classification of AR help to plan AV repair.
• Surgeon dispose of a wide armamentarium of repair techniques adapted to the variety of valvular lesions.
• Durability of leaflet repair depend on the quality and quantity of tissues; long term results are excellent for prolapse repair and acceptable for repair of restrictive lesion.
• Next to leaflet tissues quality, optimal valve coaptation and annuloplasty are other determinants of repair durability.
• Still, longer follow-up is necessary to investigate 2°decade after aortic valve repair.
• Is it durable ? Yes
Respect determinants of durabilty:
• Quality & quantity of tissue, patient selection– Type 3 (calcif., short geom. height), patch repair
• Appropriate surgical techniques– Optimal cusp coaptation, motion
– FAA stabilisation
AV repair for AI: Conclusions
Thank you
AV repair for AI: Patient demographic
• Mean age of patient with isolated AI:
- 57 y Roberts WC. Circulation 2006
- 53 ± 14 y Sharma V. JTCVS 2014
- 59 y (TAV) vs 40 y (BAV) De Meester C. AHA 2012
• Mean age of patient with aortic aneurism ± AI
- 47 ± 15 y T. David JTCVS 2014
- 57 ± 15 y T. Kunihara JTCVS 2012
- 44 ± 11 y (BAV) F.A. Kari ICVTS 2014
Johnston D.R. Ann Thor Surg 2015
Bioprosthesis durability in pts < 60 y
→ 20 – 30 % of SVD @ 15 y
Bourguignon T. ATS 2015
Bioprosthesis durability in pts < 60 y
Johnston DR. ATS 2015 Bourguignon T. Ann Thor Surg 2015
50 y
55 y
60 y
> 25 % reop. @15 y for patient < 50 y
AV repair for AI: Hospital mortality in elective surgery
• 0.6% V. Sharma, H. Schaff JTCVS 2014
• 0.8% J. Price, G. Elkhoury ATS 2013
• 0.8% D. Aicher, H-J Schafers EJCTS 2010
• 1% T. David JTCVS 2014
AV Repair: Long term Survival
V. Sharma, H. Schaff JTCVS 2014
J. Price ATS 2013 T. David JTCVS 2014
90%
81%
73%
81%
90%80%
77%
AV repair for AI: Patients
Mean age of patient with severe AI: 50 ± 17 year
- Tricuspid 59 ± 14 year- Bicuspid 40 ± 13 year De Meester C. AHA 2012
Johnston DR. ATS 2015 Bourguignon T. ATS 2015
Bioprosthesis durability in pts < 60 y
Johnston DR. ATS 2015
Bioprosthesis durability in pts < 60 y
Bourguignon T. Ann Thor Surg 2015
Johnston D.R. Ann Thor Surg 2015
Bioprosthesis durability in pts < 60 y
→ 20 – 30 % reoperation for SVD @ 15 y
• Homburg: 1995 – 2009, 430 pts, 30% BAV, 73% cusp repair
T. Kunihara JTCVS 2012
Freedom from AR ≥2+
AV repair for AI: Root dilatation (Type 1b)
AV Leaflet Repair: ResultsLong term outcomes (1995 – 2010 : 475 pts, 68% leaflet repair)
J. Price ATS 2013
84%
86%
AV Repair: Freedom from Reoperation & AI
Authors Period Cohort TechniqueFF AV Reop
FF recurrent AR >2+
H. SchaffJTCVS 2014
1986- 2011 331 Cusp 100%Sparing 0%
10 y 80% 10 y 75%
T. KuniharaJTCVS 2012
1995-2007 640 Cusp 80%Sparing 50%
10 y 88% 10 y 80%
J. Price ATS 2013
1995-2010 475 Cusp 68%Sparing 50%
10 y 86% 10 y 85%
T. David JTCVS 2014
1988- 2010 371 Cusp 50%Sparing 100%
10 y 97%
18 y 95%
10 y 93%
18 y 78%
Root pathology > Cusp pathology
AV repair for AI: TAV versus BAV
BAV
• 84% (7 y) Casselman JTCVS 1999
• 81% (10 y) Aicher EJCTS 2010
• 81% (10 y) Price ATS 2013
TAV
• 94% (12 y) David JTCVS 2010
• 93% (10 y) Aicher EJCTS 2010
• 89% (10 y) Price ATS 2013
Freedom from reoperation
<