Aortic Valve Repair: The Brussels Approach · Aortic Valve Repair: The Brussels Approach Laurent de...
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Aortic Valve Repair: The Brussels Approach Laurent de Kerchove, MD, PhD
Cliniques Universitaires St-Luc, IREC, UCL, Brussels, Belgium
Reconstruction of the Aortic Valve and Root: A Practical Approach
September 14th-16th , Homburg/Saar, Germany
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AV repair program in Brussels
• 1994
• 1996 – 2016: 850 Aortic valve repair/sparing
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Congenital
- Bicuspid
- Connective tissue disorders (Marfan, Loeys-Dietz, Ehler-Danlos, Familial Aneurysmal disease, …)
- Unicuspid
- Quadricuspid
- Supra-aortic stenosis
Pathologies amenable to AV repair
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Acquired
- Degenerative cusp
- Degenerative aortic aneurysm
(Atherosclerosis)
- Traumatic
- Infectious
- Acute aortic dissection
Pathologies amenable to AV repair
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Redo
- Ross repair
- Re-repair
Pathologies amenable to AV repair
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Dysfunction
Etiology
Lesion
Functional classification of AI Lesson from the mitral valve
Prolapse eccentric MI
MV FED
Cordale rupture
Cusp tethering central AI
AV Marfan
Root dilatation
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Functional classification of AI Lesson from the mitral valve
A. Carpentier
Type II
Leaflet prolapse
Type III a,b
Leaflet restrictive motion
Type I
Annulus dilatation
Common language
Plan surgical strategy
Predict the outcomes
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The Functional Aortic Valve Unit
1. Cusp
2. STJ
3. VAJ
Functional classification of AI
FAA
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Functional classification of AI
El Khoury G. Cur. Op. Card. 2005
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Type 1: “FAA Dilatation”
Type 1a
Asc. Ao. (STJ)
Type 1b
Root (STJ +VAJ) Type 1c
VAJ
Functional classification of AI
31 mm
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Type 1a and 1b: STJ dilatation
Functional restriction of the cusp (tethering) → central AI
Effective height = supra normal (>9-10mm)
Free margin elongation
Commissural fenestration
Functional classification of AI
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Type 1b and 1C: VAJ dilatation
Effective height = infra normal (<9-10mm)
Frequently associated with cusp prolapse
Dilated VAJ
Normal VAJ
Functional classification of AI
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Type 2: “Prolapse”
Eccentric jet
Cusp billowing
Transverse fold in cusp curvature
M. Boodhwani, JTCVS 2013
Functional classification of AI
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Functional classification of AI
Type 2: “Prolapse”
Transverse fold in cusp curvature
= Free margin elongation
below other normal FM
Commissural fenestration
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Type 3: Restrictive cusp motion
Functional classification of AI
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Type 3: Restrictive cusp motion
Functional classification of AI
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Type 1d: Cusp perforation/destruction
(no prolapse, no restriction)
Functional classification of AI
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Type 1b+2 Type 1c+2
Functional classification of AI
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Principles of AV repair
1. Restore and preserve cusp geometry and motion
2. Remodel and stabilize the FAA +
Optimal area of coaptation, stable over time
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Pethig K. ATS 2002 le Polain JB. JACC Card. Im. 2009
Tips < annulus
Tips > annulus, Residual AR, Coapt L <4 mm
Residual AR, Coapt L >4 mm
Tips > annulus, No AR
Principles of AV repair: Optimal coaptation
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Principles of AV repair: Optimal coaptation
Schafers H.J. JCTVS 2006 Bierbach B.O., EJCTS 2010
Aicher D. Circ. 2011
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Cusp lesions
• Prolapse (type 2)
- Free margin elongation
- Fenestration
- Commissure disruption
• Restriction/retraction (type 3)
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction (type 1d)
Repair techniques
→ Central plication or Goretex resuspension
→ Goretex resuspension or Patch
→ Commissure reattaching or Patch
→ Resection + direct closure or patch
→ Resection + Patch
→ Resection + Patch
→ Patch
Techniques of cusp repair
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration
- Commissure disruption
• Restriction/retraction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction
Repair techniques
→ Central plication
Techniques of cusp repair
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Central Plication Technique: 1 cusp prolapse
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Central Plication Technique: 1 cusp prolapse
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Central Plication Technique: 1 cusp prolapse
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Central Plication Technique: 1 cusp prolapse
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Central Plication Technique: 1 cusp prolapse
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Central Plication Technique: 1 cusp prolapse
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Central Plication Technique: 1 cusp prolapse
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1/2
1/2
LCC NCC
≈ 9-10 mm eH
Central Plication Technique: 3 cusps prolapse
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1/2
1/2
LCC NCC
≈ 9-10 mm eH
Central Plication Technique: 3 cusps prolapse
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1/2
1/2
LCC NCC
≈ 9-10 mm eH
Central Plication Technique: 3 cusps prolapse
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration
- Commissure disruption
• Restriction/retraction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction
Repair techniques
→ Central plication
Techniques of cusp repair
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration « small »
- Commissure disruption
• Restriction/retraction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction
Repair techniques
→ Central plication + Gtx Resuspension
Techniques of cusp repair
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration « large »
- Commissure disruption
• Restriction/retraction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction
Repair techniques
→ Patch repair (2 patches) + Gtx resuspension
Techniques of cusp repair
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration « rutpured »
- Commissure disruption
• Restriction/retraction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction
Repair techniques
→ Patch repair (butterfly techn.) + Central Plication
Techniques of cusp repair
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration
- Commissure disruption
• Restriction/retraction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction
Repair techniques
→ Comm. reattachment + Goretex resuspension
Techniques of cusp repair
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration
- Commissure disruption
• Restriction/retraction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction
Repair techniques
→ Resection direct closure + VS Reimplantation
Techniques of cusp repair
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration
- Commissure disruption
• Restriction/retraction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction
Repair techniques
→ Resection + Patch repair
Techniques of cusp repair
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration
- Commissure disruption
• Restriction/retraction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction
Repair techniques
→ Resection + Patch repair
Techniques of cusp repair
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration
- Commissure disruption
• Restriction/retraction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction
Repair techniques
→ Cusp extension with patch
Techniques of cusp repair
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration (large/rutpured)
- Commissure disruption
• Restriction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/Destruction
Repair techniques
→ Patch repair
Techniques of cusp repair
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Boodhwani M. JTCVS 2010
P=0.02
M. Boodhwani, JTCVS 2009
Freedom from AR >2+
P=0.03
Freedom from AR >2+
Techniques of cusp repair: Outcome following type of AI
BAV repair All repair cohort
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Aorta lesions
• Type 1a: Asc Ao (STJ)
• Type 1b: Root (STJ + VAJ)
• Type 1c: VAJ
Repair techniques
→ Supra coronary ascending aorta replacement
→ Valve Sparing Reimplantation
→ Subcommissural annuloplasty or Ring annuloplasty
Techniques of FAA repair
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Aorta lesions
• Type 1a: Asc Ao (STJ)
• Type 1b: Root (STJ + VAJ)
• Type 1c: VAJ
Repair techniques
→ Supra coronary ascending aorta replacement
Techniques of FAA repair
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Aorta lesions
• Type 1a: Asc Ao (STJ)
• Type 1b: Root (STJ + VAJ)
• Type 1c: VAJ
Repair techniques
→ Valve Sparing Reimplantation
Techniques of FAA repair
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1. Valve inspection
2. Root dissection
3. Complex cusp repair
4. Graft sizing & proximal suture line
5. Com. reimplantation & distal suture line
6. Residual prolapse repair
7. Coronary reimplantation
VS Reimplantation: Brussels Technique
N/L L/R R/N
L/R R/N N/L
STJ
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Aorta lesions
• Type 1a: Asc Ao dilat (STJ)
• Type 1b: Root (STJ + VAJ)
• Type 1c: VAJ
Repair techniques
→ Subcommissural annuloplasty or Ring annuloplasty
Techniques of FAA repair
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Ring annuloplasty
Techniques of FAA repair
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TAV BAV
SCA: Root < 45 mm
VSR: Root > 45 mm
Techniques of FAA repair
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De Kerchove L. EJCTS 2015
TAV
FF AR >1+
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
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
VAJ <28mm
VAJ ≥28mm
Techniques of FAA repair Subcommissural annuloplasty and VAJ size
Navarra E. EJCTS 2013
BAV
FF AR >1+ FF AR >1+
VAJ <30mm
p < 0.01 VAJ ≥30mm
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30 y♂: BAV, rapher res+direct closure, cusps resusp (Gtx), SCA → 6.5 y later: AI 3+
VAJ dilatation
41 y ♂: TAV, RC plication and resuspension (Gtx), SCA → 2 y later : AI 3+
29 mm
Preop TEE
29 mm
Pre-redo TEE
24 mm
Postop TEE
31 mm
Preop TEE
31 mm
Pre-redo TEE
22 mm
Postop TEE
Techniques of FAA repair SCA and VAJ size
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Techniques of FAA repair VS Reimplantation and VAJ size
BAV
Navarra E. EJCTS 2013
FF AR >1+
VAJ <30mm
VAJ ≥30mm
p = 0.93
FF AR >1+
TAV
De Kerchove L. EJCTS 2015
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
VAJ <28mm
VAJ ≥28mm
p = 0.4
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p=ns p<0.001
De Kerchove L. EJCTS 2015
Techniques of FAA repair SCA and VAJ size
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Normal Root (<40 mm)
Normal VAJ (<28 mm) «Old patient» (>50 y)
Dilated Root (≥40 mm)
Large VAJ (≥28 mm)
Subcom. annuloplasty VS Reimplantion
Large VAJ (≥28 mm) Root wall fragility
Remodel BAV geometry 180°
External Ring Annuloplasty
Brussels annuloplasty strategy (AV repair for severe AI)
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Thank you
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Main goal of AV repair: Optimal coaptation + Stabilisation
Pethig K. ATS 2002 le Polain de Waroux JB. JACC Card. Im. 2009
Bierbach BO. EJCTS 2010 Aicher D. Circ. 2011
De Kerchove L. JTCVS 2011
• Effective height (eH) ≥ 9 mm
• Coaptation length ≥ 4 mm
• Circumferential annuloplasty VAJ ≥28
• No residual AI
• Good cusp mobility
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Brussels AV repair: Conclusions
• The mechanisms of AI are actually well understood and the use of a classification help to discuss indication, plan surgical strategy and analyze the outcomes.
• 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 in Type 1 (FAA dilatation) and 2 (Prolapse) and acceptable in type 3 (Restrictive).
• Next to leaflet tissues quality, optimal valve coaptation and annuloplasty are the principal determinants of repair durability.
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AV Repair: Hospital Mortality (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
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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%
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AV Repair: Freedom from Reoperation & AI
Authors Period Cohort Technique FF AV Reop
FF recurrent AR >2+
H. Schaff JTCVS 2014
1986- 2011 331 Cusp 100% Sparing 0%
10 y 80%
10 y 75%
T. Kunihara JTCVS 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
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AV Repair: Valve sparing in Marfan Syndrome
T. David, JTCVS 2009
Freedom from AR >2+ Freedom from AV reoperation
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AV Repair: Leaflet repair in valve sparing surgery
H.J. Schäfers ATS 2002 L. de Kerchove Circ. 2009
Cusp repair = risk factor of reoperation or recurrent AR • E. Lansac EJCTS 2010 (negative impact of cusp repair decrease with experience) • P.P. Urbanski EJCTS 2012
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AV repair Risk factor of repair failure: Cusp coaptation
Pethig K. ATS 2002
le Polain JB. JACC Card. Im. 2009
Tips < annulus
Tips > annulus Residual AR Coapt < 4 mm
Residual AR, Coapt >4 mm
Tips > annulus, No AR
Aicher D. Circ. 2011
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Aicher D. Circ. 2011
AV repair Risk factor of repair failure: VAJ dilatation
Navarra E. EJCTS 2013
No annuloplasty SC annuloplasty
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AV repair 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
<
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AV repair Valve sparing reimplanation in BAV repair
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+
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AV repair for AR
Normal Root (<45 mm)
Normal VAJ (<26 mm)
Dilated Root (≥45 mm)
Large VAJ (>26 mm)
Subcom. Anpl. VS Reimplantation
Large VAJ (>26 mm) + Modify valve geometry
Ring Annuloplasty
AV repair Aorta/Annuloplasty repair strategy
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AV repair Risk factor of repair failure: Patch repair
Aicher D. Circ. 2011 Boodhwani M. JTCVS 2010
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AV repair: Probability of Cusp Repair in valve sparing surgery
• No AR → low 10 %
→ Moderate 30-50 %
• AR, central jet
→ High ≈ 100 %
• AR, eccentric jet
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AV Repair: Valve related event
• Thromboembolic event 0.2 % - 0.7% /y
92-95% @ 10 y; 87- 90% @ 15 y
• Endocarditis 0.2% /y
• All VRE (reop, thromb, bleed, endoc)
74 - 90% @ 10 y; 80% @ 18 y
V. Sharma, H. Schaff JTCVS 2014 J. Price, G. Elkhoury ATS 2013
D. Aicher, H-J Schafers EJCTS 2010 T. David JTCVS 2014
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AV Repair: Prolapse repair (Type 2)
M. Boodhwani, JTCVS 2011
93%
93%
87%
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AV Repair: Leaflet repair with patch
Mozala Nezhad Z. EJCTS 2014
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Adequate
Restrictive Prolapsing
Inadequate
Cusp Anatomy
Type 0 Type 1
Central Plication,
Triangular Resection
Raphe Morphology
Quantity of Cusp Tissue ?
≈ 180°
Triangular
Patch
Raphe Resected Raphe
Thinned
≈ 120°
Commissural
Patch
BAV Repair
≈ 180° ≈ 120°
Tricuspidisation
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AV Leaflet Repair: Results Unicuspid valve repair
• 2001 – 2011: 118 pts • mean age: 27 years • FF reoperation @ 3 years: 80% 86 %
D. Aicher JTCVS 2013
Design I Design II
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In patients with chronic AR, the severity of AR is correlated with the degree of STJ and VAJ dilatation
Padial LR, Am Heart J. 1997
Keane MG, Circulation. 2000
Functional classification of aortic regurgitation Mechanism of AV dysfunction
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Type I characteristics
Central jet ∟ to subvalvular plane
all cusps have same coaptatin hight
lack of central coaptation
Functional classification of aortic regurgitation Mechanism of AV dysfunction
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Principles of AV repair/sparing surgery Optimal coaptation ?
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Central Plication Technique: 2 cusp prolapse
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Central Plication Technique: 2 cusp prolapse repair
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Central Plication Technique: 2 cusp prolapse
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Central Plication Technique: 2 cusp prolapse
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Central Plication Technique: 2 cusp prolapse
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Central Plication Technique: 2 cusp prolapse
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Central Plication Technique: 2 cusp prolapse
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Central Plication Technique: 2 cusp prolapse
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Central Plication Technique: 2 cusp prolapse
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Central Plication Technique: 2 cusp prolapse
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• In tricuspid 52%
• In bicuspid 93%
AV morphology
T. David JTCS. 2006: ±58%
D. Aicher. JTCS 2007: ±53%
D. Aicher. JTCS 2007: ±86%
Reimplantation Technique Probability of Cusp Repair
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• In tricuspid 52%
Preoperative AR
30
56 57
0
20
40
60
80
100
AR 0-1+ AR 2+ AR 3+
D. Aicher. JTCS 2007
E. Lansac EJCTS. 2010
Reimplantation Technique Probability of Cusp Repair
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70
2010
0
20
40
60
80
100
1 cusp 2 cusps 3 cusps
70
3625
0
20
40
60
80
100
RCC LCC NCC
Reimplantation Technique Probability of Cusp Repair
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• In tricuspid 52%
• In bicuspid 93%
Preoperative AR Operarive period AV morphology
30
56 57
0
20
40
60
80
100
AR 0-1+ AR 2+ AR 3+
90 90 98
40
50
60
70
80
90
100
AR 0-1+ AR 2+ AR 3+
32
54 50
0
20
40
60
80
100
99-03 04-07 08-11
80
96 96
40
50
60
70
80
90
100
99-03 04-07 08-11
D. Aicher. JTCS 2007
E. Lansac EJCTS. 2010
Reimplantation Technique Probability of cusp repair
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• In tricuspid
Preoperative AR 0-1+
66
33 33
43
27
43
0 00
20
40
60
80
100
2004 2005 2006 2007 2008 2009 2010 2011
Reimplantation Technique Probability of cusp repair
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Reimplantation Technique Water Test, residual prolapse repair
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AV Repair
Surgery for AI
• Symptomatic severe AI
• Assympt severe AI + EF <50%
or + LVED >65 (70) mm, LVES >50 mm
Surgery for Ao. Aneurism
• > 55 mm in TAV
• > 50 mm in Marfan, BAV at risk
• > 45 mm in Marfan at risk, if surgery for severe AI
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1-2%/y
2. Patients selection for AV repair
1. Pediatric
2. Young adults
3. > 65 years
Main TARGET of AV repair
= 23% of AV repair population (1996 – 2012, 620 pts)
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BAV Repair Classification of cusp phenotypes
H. Sievers, J.Thor. Cardiovasc.Surg. 2007
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Cusp lesions
• Prolapse
- Free margin elongation
- Fenestration « large »
- Commissure disruption
• Restriction
- Raphe in BAV
- Unicuspid valve
- Fibosis/Calcification
• Perforation/destruction
Repair techniques
→ Patch repair (2 patches)
Techniques of cusp repair
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BAV repair Classification of cusp phenotypes
• Raphe • Complete fusion • 160° – 180° • Prolapse
• Thick, calc. raphe • Incomplete fusion • 120° – 160 ° • Restrictive
Type 1 (Sievers classif.)
• ≈ 180° • No raphe • Prolapse
Type 0 (Sievers Classif.)
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BAV Repair Aortopathy
Dilated Asc. Aorta Dilated Root
• Dilated ventriculo-aortic junction 28 – 30 mm de Kerchove JTCVS 2010
Schäfers JTCVS 2013
Normal Aorta
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1. Circumferential prosthetic based annuloplasty 2. Modify commissure orientation (≈180°)
• Improve durability • Reduce the need of patch repair
160°
180°
BAV repair Valve sparing Reimplantion
Type 1 BAV
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Techniques of FAA repair SCA vs VSR (matched comparison)
BAV
De Kerchove L. JTCS 2010
FF AR >1+
TAV FF AR >1+
De Kerchove L. EJCTS 2015
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
VSR
SCA
p = 0.04