Aortic Valve Repair Introduction · Aortic Valve Repair – Introduction H.-J. Schäfers Dept. of...
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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
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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%)
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Mortality
VR complications
Reoperation
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Survival
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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
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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‘
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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
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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
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Freedom from Reoperation
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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