Surgical Approach to Aortic Insufficiency · 2019. 11. 12. · understanding the functional aortic...
Transcript of Surgical Approach to Aortic Insufficiency · 2019. 11. 12. · understanding the functional aortic...
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Surgical Approach to Aortic InsufficiencyJ E N N I FE R C H U N G M D M S C F RC S C
C A RD I O VA SC ULA R S U RG EO N/ TO RO NTO G E N E RA L H O S P I TA L
N O V E M BE R 3 , 2 0 1 9
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Outline
Surgical Anatomy
Classification of AI
Common Surgical Strategies
Evidence for Aortic Valve Repair
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Surgical AnatomyLET ’S SPEAK THE SAME LANGUAGE
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The Functional Aortic Annulus
Sinotubular junction
Basal ring
Crown-shaped aortic annulus
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The Functional Aortic Annulus
Aortic AnnulusThe Virtual Basal Ring
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The Functional Aortic Annulus
Ventricular-aortic junctionthe VAJ
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Classification of Aortic InsufficiencyINFORMS SURGICAL REPAIR CHOICES
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Inter-commissural distance
Commissure
Free margin
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Q1: What is the condition of the leaflets
Thin and pliable versus Thickened, calcified nodules
Small fenestrations versus Large, in the belly of the leaflet
Long and prolapsing versus Short and furled free margin
Schafers, Homburg, Germany
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Q2: What is the condition of the FAA?
➢STJ dilated? Then STJ remodeling
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Q2: What is the condition of the FAA?
➢STJ dilated? Then STJ remodeling
➢Annuloaortic ectasia? Then basal ring remodeling
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Q2: What is the condition of the FAA?
➢STJ dilated? Then STJ remodeling
➢Annuloaortic ectasia? Then basal ring remodeling
➢Sinuses of Valsalva? Then the root should be replaced (VSRR versus Bentall)
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Quick case example
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Repair strategy
Aneurysm – needs replacement of the ascending aorta and hemiarch replacement
But what about the severe AI?
Q1: Leaflet quality: Thickened, Geometric height 17mm
Q2: Basal ring is small, Root not dilated, STJ is distracted
STJ remodeling!
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Finer points
- Small basal ring, short leaflets, 26 mm graft chosen
- Anticipate central jet given thickened leaflets
- Best practice to reinspect the valve after STJ remodeling
- Separate graft for hemiarch replacement, and then graft to graft
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Evidence for Aortic Valve RepairLONG-TERM OUTCOMES
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Beware patients who require
significant de-calcification or
extensive patch-work
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Technique optimizes long-term durability
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Technique optimizes long-term durability
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Take-Home MessagesUNDERSTANDING THE FUNCTIONAL AORTIC ANNULUS INFORMS SURGICAL REPAIR STRATEGIES
EXCELLENT LONG-TERM RESULTS FOR AORTIC VALVE REPAIR FOR AORTIC INSUFFICIENCY IF CHOOSE THE RIGHT PATIENTS AND THE RIGHT TECHNIQUES