Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic...
Transcript of Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic...
![Page 1: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/1.jpg)
Aortic Valve Repair - Alternative to Replacement
An Introduction
H.-J. Schäfers
Dept. of Thoracic and Cardiovascular Surgery
University Hospital of Saarland
12.09.2018
![Page 2: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/2.jpg)
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.»
12.09.2018 2
“Practice should always be based upon a sound knowledge of theory.
Without this guidance and door nothing will be done well”
![Page 3: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/3.jpg)
12.09.2018 3
![Page 4: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/4.jpg)
12.09.2018 4
Aortic Valve - Historic Repair Attempts
Taylor et al., J Thorac Surg 1958
![Page 5: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/5.jpg)
12.09.2018 5
Aortic Valve Replacement
Thromboembolism
Anticoagulation/Hemorrhage
Structural failure
PV endocarditis
Incidence of valve-
related complications
Hammermeister et al, JACC 2000
![Page 6: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/6.jpg)
12.09.2018 6
AVR - Mechanical Prosthesis-Related Complications
Years after valve replacement
Ikonomidis JS, JTCVS 2003
![Page 7: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/7.jpg)
Mohty D, Curr. Card. 2002
Repair vs. Replacement (Mitral)
![Page 8: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/8.jpg)
12.09.2018 8
Root Repair – Technical Options
(Yacoub 1993)
(David 1992) (Frater 1986)
(Sinus < 45 mm)
Reimplantation
of Aortic Valve Root Remodeling ST Junction
Remodelling
(Cabrol 1966)
Subcommissural
Plication
![Page 9: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/9.jpg)
12.09.2018 9
Aortic Valve Repair
![Page 10: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/10.jpg)
12.09.2018 10
Aortic Valve Repair
![Page 11: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/11.jpg)
12.09.2018 11
![Page 12: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/12.jpg)
12.09.2018 12
Reimplantation Remodeling
2 l/min
![Page 13: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/13.jpg)
12.09.2018 13
![Page 14: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/14.jpg)
12.09.2018 14
CE = π × [3/2×(a+b) - √a×b]
a
b ≈ raorta
a ≈ rcusp rcusp ≈ 1 / raorta
Reduction of STJ and Cusp Prolapse
b
a‘ b‘
![Page 15: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/15.jpg)
12.09.2018 15
Aortic Valve Repair - Difficulties
Dimensions- of aortic root/(ring)
![Page 16: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/16.jpg)
R
NC L
Functional Aortic Annulus / Basal Ring
Lansac E et al. ATS 2015
![Page 17: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/17.jpg)
12.09.2018 17
Aortic Valve Repair - Difficulties
Vision from outflow
Configuration/coaptation of cusps
![Page 18: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/18.jpg)
12.09.2018 18
Aortic Valve Repair - Difficulties
Geometry altered by
non-pressurized state
![Page 19: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/19.jpg)
12.09.2018 19
Solutions
Geometry altered by non-pressurized state!
Stay sutures!
![Page 20: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/20.jpg)
12.09.2018 20
Aortic Valve Repair - Assessment
Solutions
Configuration/coaptation of cusps
Swanson, Circ Res 1974
?
![Page 21: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/21.jpg)
12.09.2018 21
effective height
1cm
Cusp Configuration
Schäfers HJ et al, JTCVS 2006
![Page 22: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/22.jpg)
12.09.2018 22
Effective Height effective height
1cm
![Page 23: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/23.jpg)
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%
Sen
sit
ivit
y %
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
![Page 24: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/24.jpg)
![Page 25: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/25.jpg)
12.09.2018 25
Higher effective height leads to improved coaptation height
![Page 26: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/26.jpg)
12.09.2018 26
Configuration/coaptation of cusps
![Page 28: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/28.jpg)
12.09.2018 28
Aortic Valve Repair - Assessment
Solutions
Configuration/coaptation of cusps
![Page 29: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/29.jpg)
12.09.2018 29
Aortic Valve Repair - Assessment
Configuration/coaptation of cusps
TAV: 18-22 mm
BAV: 20-25 mm
![Page 30: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/30.jpg)
12.09.2018 30
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=42
Prolapse
Congenital
Retraction
![Page 31: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/31.jpg)
12.09.2018 31
Aortic Valve – Stress Distribution
![Page 32: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/32.jpg)
12.09.2018 32
Reconstructive Techniques
Cusp Pathology
Plication of
Cusp Margin
Prolapse
![Page 33: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/33.jpg)
12.09.2018 33
Aortic Valve Repair
Freedom from Valve-related Complications
Incidence of valve-
related complications
Hammermeister et al, JACC 2000
86%
![Page 34: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/34.jpg)
12.09.2018 34
![Page 35: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/35.jpg)
Freedom from Reoperation
![Page 36: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/36.jpg)
Annular dilatation effects coaptation
![Page 37: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/37.jpg)
![Page 38: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/38.jpg)
![Page 39: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/39.jpg)
12.09.2018 39
Root Repair – Technical Options
(Cabrol 1966)
Subcommissural
Plication Aortic Annuloplasty
(AVJ > 25-27mm)
![Page 40: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/40.jpg)
![Page 41: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/41.jpg)
Freedom from Reoperation – BAV
Predictors of Failure
p p
univar. multivar.
Patient age < 40 yrs. 0.0051 0.001
Orientation of comm. (<160°) 0.0001 0.002
Non-root replacement 0.0018
Cabrol suture 0.04
Pericardial patch 0.0001 0.0001
AV diameter (>28 mm) 0.0005 0.007
ST diameter (≤ 30 mm) 0.0142
Effective height < 9mm 0.0013 0.002
Preop AR > III 0.0029
![Page 42: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/42.jpg)
Aortic Valve Reconstruction • AV reconstruction is on its way to a rational and reproducible
• approach (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 biprostheses in young patients
• AV reconstruction should be considered in every patient with AR
12.09.2018 42
![Page 43: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/43.jpg)
12.09.2018 43
Thank you for your attention
Thank you for your attention
![Page 44: Aortic Valve Repair - Alternative to Replacement An ... · 12.09.2018 4 Aortic Valve - Historic Repair Attempts Taylor et al., J Thorac Surg 1958](https://reader033.fdocuments.in/reader033/viewer/2022060316/5f0bfd9b7e708231d43337d3/html5/thumbnails/44.jpg)
12.09.2018 60
Root Repair – Technical Options
(Cabrol 1966)
Subcommissural
Plication
THG
?
Aortoventricular Plication
(AVJ > 27mm)