Aortic Regurgitation and Aorti Repair II

(1)

Aortic Regurgitation and

Aortic Leaflet Repair

Cesare

(2)

Clinical Scenario

• A 48-year-old woman presenting with mild

fatigue but no other symptoms, found to have a

3/6 diastolic cardiac murmur.

• BP 160/60 mm Hg; bounding peripheral pulses

• Auscultation: decreased S1 and increased S2

intensity

• TTE: bicuspid aortic valve with an eccentric jet

of severe aortic regurgitation

• LVEDD - 66 mm or 39 mmM

2

of BSA

• LVESD - 46 mm or 27 mmM

2

of BSA

• Ejection fraction - 51%

(3)

Cause

of AR

_{of AR}

• Developing Countries: rheumatic disease

• Western Countries

• In rare cases, aortic regurgitation is acute

(Endocarditis, Aortic Dissection, Trauma)

Congenital (Bicuspid Valve)

Degenerative (annulo-ectasia)

(4)

Aortic Regurgitation

Prevalence of AR is 4-7% of the population

prevalence with age

Severe regurgitation observed in men than

women

(5)

Pathophysiology

Increase in EDV and EDP

Total SV= Regurg. Vol + forward SV

LV volume overload ( indicated by enlarged LV on ECHO )

LV pressure overload ( indicated by increase end-systolic pressure )

BUT

Symptoms develop slowly because Left atrial pressure increase late in the course of the disease

(6)

Symptoms

Left sided heart failure:

Dyspnoea, orthopnoea, fatigue, paroxysmal

nocturnal dyspnoea

Syncope and Angina due to reduced aortic

diastolic BP

(7)

Signs

Hyperdynamic circulatory state accounts the

clinical signs of AR:

• Hyperkinetic apical impulse

• Increased systolic pressure and decreased

diastolic pressure

• Bounding pulses

• Widened pulse pressure

Loud early diastolic murmur

Austin Flint murmur – MDM, maybe heard in

severe AR, due to premature closure of MV by

regurgitant jet and from the rapid increase in left

ventricular diastolic pressure and making MV

(8)

Natural History

Pts with Acute AR have poor prognosis

without intervention

Pts with Severe chronic AR in NYHA class

III IV have an annual mortality of 25%

Pts with Severe chronic AR in NYHA class

II have an annual mortality of 6.3%

(9)

Natural History

Pts asymptomatic with marked LV enlargment are

associated with an increase risk (2%) of sudden

death compared with the general population

Pts asymptomatic without LV dysfunction do not

have any excess risk of death

as compared with

the general population, but do have high

cardiovascular event rates (i.e., heart failure, or

new symptoms) at 5 to 6 % per year

(10)

Diagnosis

• Clinical examination

• ECHO = Gold Standard

• TOE

• CMR

• Angiogram

(11)

Echo assessment of AR

• Anatomy:

Diameter of annulus, S of Valsalva , STJ,

AA, Aneurysm, Bicuspidy, LV diameter…

• Mechanism:

Dissection, Aneurysm of Aortic root, Leaflet

prolapse, Endocarditis, Degenerative

(12)

Echo assessment of AR

Holodiastolic reversal flow in the descending aorta (= abdominal aorta).

(13)

Timing of Surgery

(14)

Management Strategy for

Aortic Regurgitation

(15)

Surgical options

• Aortic valve replacement

Mechanical

Bioprosthetic/Biological (

Stentles – Stented

)

Problem with younger adult pts associated to anticoagulation and/or

prosthesis durability

Xenograft Homograft Allograft Bovine

(16)

Surgical options

• Aortic Valve repair

If durable has the potential to be a good

solution in younger adult pts

(17)

Clinical anatomy of the

aortic root

The aortic root is positioned to the right and postirior relative to the subpulmonary infundibulum

(18)

Clinical anatomy of the

aortic root

Forming the outflow tract from the LV and its function is supporting structure for the Aortic Valve, delineated superioly by the STJ and inferiorly by the VAJ

Devided in :

Structures distal to the attachments of the valvar leaflets ( Valvar Sinus)

Structures proximal to the attachments of the valvar leaflets ( interleaflet or fibrous triangles)

(19)

Clinical anatomy of the

aortic root

The aortic root has been opened through a longitudinal incision across the area of aortic-mitral valvar continuity, and spread open to show the semilunar attachments of the valvar leaflets. Note the interleaflet triangles extending to the sinutubular

(20)

Clinical anatomy of the

aortic root

The valve leaflets are inserted into the aortic wall in a semilunar

Fashion and their closure

determined the valve competence in the central coaptation area;

the level of the coaptation is at the middle distance between the nadir of their insertion and the

(21)

Aortic Valve Repair

Techniques of aortic valve repair have been documented for over 40 years.

Starr and associates first reported a technique for aortic repair in 1960 [1]

This was followed by two case reports of aortic valve repair by

Spencer in 1962 and later Trusler in 1973 [2,3]

In the early 1980’s, as percutaneous balloon valvotomy was performed

[1] Starr A, Menashe V, Dotter D. Surgical correction of aortic insufficiency associated with ventricular septal defect. Surg Gynecol Obstet 1960;111:71–

[2] Spencer FC, Bahnson HT, Neill CA. The treatment of aortic regurgitation associated with a ventricular septal defect. J Thorac Cardiovasc Surg 1962;43:222–33

(22)

The functional classification of aortic root

abnormalities

responsible for aortic insufficiency

Functional classification of aortic root/valve abnormalities and their correlation with etiologies and surgical procedures El Khoury et All Curr Opin Cardiol. 2005

Mar;20(2):115-21. Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium.

(23)

The functional classification of aortic root

abnormalities

responsible for aortic insufficiency

The aim of this classification

is to provide a simple

guide in the diagnosis of

major abnormalities so

that corrective surgical

techniques can then be

applied to each identified

abnormality

(24)

Surgical procedures

Type Ia lesions are treated by reduction of the circumference of the Sino-tubular junction and is usually achieved by replacing the ascending aorta with an

appropriately sized Dacron graft.

Ideally, its diameter

should be approximately the size of the native

aortic annulus

(25)

Surgical procedures

Type Ib lesions are treated by an aortic valve sparing operation,

Remodeling of the aortic root Reimplantation of the aortic valve with creation of neo-aortic sinuses

(26)

Surgical procedures

For the Type Ic the most appropriate surgical procedure

may be a partial sub-commissural annuloplasty or circular

Circular Annuloplasty

Type Ic: isolated FAA dilation

(27)

Surgical procedures

Type Id: cusp perforation and FAA dilation

Type Id lesions are

treated by patch

closure.

For large defects

autologous tricuspid

leaflet tissue is used

rather than autologous

pericardium in the hope

that will remain free from

calcification

(28)

Surgical procedures

Type II Cusp prolapse:

LP repair with central plication. The normal free margin taken as reference Plication is extended with a short running suture, perpendicular to the free margin, 4—5 mm through

(29)

Surgical procedures

Type II Cusp prolapse Gore-Tex resuspension (GTx)

Resuspension with running suture of Gore-Tex 7/0. The 7/0 Gore-Gore-Tex suture is

passed twice in the top of the commissure. Successively, two running sutures are

passed over and over around the length of the free margin

With gentle traction on each branch of the Gore-Tex sutures and applying

opposite resistance with a forceps the free margin is shortened by slightly wrinkling the tissue

(30)

Surgical procedures

Type II Cusp prolapse:The triangular resection

The triangular resection involves excising a triangle of tissue in the middle of the

prolapsing valve and then suturing the edges back together.

A continuous suture is recommended instead of interrupted sutures because it decreases the chance of a leak and

(31)

Surgical procedures

Type III Restrictive Cuspid motion

Shaving, decalcification and valve extension with Three strips of

pericardium, 3–8 mm that are sewn to the free

edges of the valve cusps to extend them and

increase the surface area for coaptation

(32)

Results: The Brussels Experience

(33)

Results: The Brussels Experience

(34)

Results: The Brussels Experience

Actuarial survival curves. (a) Freedom from AR grade >2 in subgroups of patients having leaflet plication (PL), Gore-Tex resuspension (GTx) or the combination of PL + GTx and (b) freedom from AR grade >2 in subgroups of patients having triangular resection (TR) or pericardial patch repair (PP) alone or in combination

(35)

Result AV Sparing with AV Repair

(a) Actuarial survival curve. (b) curve for freedom from recurrence of aortic regurgitation exceeding grade 2 or stenosis (including early and late recurrences)

(36)

Results

(37)

Results

(38)

Results

Aortic valve repair for aortic insufficiency in adults: a contemporary review and comparison with replacement techniques John Alfred Carra, Edward B. Savagea,b,* European Journal of Cardio-thoracic Surgery 25 (2004) 6–15

(39)

Dis

cussion

_cussion

The optimal treatment of aortic

insufficiency would be to replace or

repair the valve to its pre-disease

state, without the need for long-term

anticoagulation and obtain life-long

durability.

(40)

Dis

cussion

_cussion

The risk of thromboembolism and infectious endocarditis is roughly equivalent The durability for valve repair seem less favorable than bioprosthetic replacement. ( difficoult comparison, Biopro mean age 72, repair mean age 36 )