aortic regurgitation and aorti repair ii

8/17/2019 Aortic Regurgitation and Aorti Repair II

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Aortic Regurgitation andAortic Regurgitation andAortic Leaflet RepairAortic Leaflet Repair

CesareCesare Quarto MDQuarto MD


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Clinical ScenarioClinical Scenario • A 48-year-old woman presenting with mild

fatigue but no other symptoms, found to have a3/6 diastolic cardiac murmur.

• ! "6#/6# mm $g% bounding peripheral pulses• Auscultation& decreased '" and increased '(

intensity• ))*& bicuspid aortic valve with an eccentric +et

of severe aortic regurgitation• * - 66 mm or 3 mm0 ( of 'A• *' - 46 mm or (1 mm0 ( of 'A• *+ection fraction - 2"

$ow should this patient be treated


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CauseCause of ARof AR

• Developing Countries: rheumatic disease

• Western Countries

• In rare cases, aortic regurgitation is acute(Endocarditis, Aortic Dissection, Trauma)

Congenital (Bicuspidalve)

Degenerative(annulo!ectasia)


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Aortic RegurgitationAortic Regurgitation

"revalence o# A$ is %!&' o# the population

prevalence ith age

evere regurgitation o*served in men thanomen( +ramingham eart tud-)


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PathophysiologyPathophysiology

Increase in ED and ED"

Total . $egurg/ ol 0 #or ard

1 volume overload ( indicated *-enlarged 1 on EC 2 )

1 pressure overload ( indicated *-increase end!s-stolic pressure )

5)

-mptoms develop slo l- *ecause 1e#t atrial pressure increase late inthe course o# the disease


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SymptomsSymptoms

1e#t sided heart #ailure:D-spnoea, orthopnoea, #atigue, paro3-smalnocturnal d-spnoea

-ncope and Angina due to reduced aortic

diastolic B"2ccasionall- carotid arter- pain


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SignsSigns

-perd-namic circulator- state accounts theclinical signs o# A$:

• -per4inetic apical impulse

• Increased s-stolic pressure and decreaseddiastolic pressure• Bounding pulses• Widened pulse pressure

1oud earl- diastolic murmur Austin +lint murmur 5 6D6, ma-*e heard insevere A$, due to premature closure o# 6 *-regurgitant 7et and #rom the rapid increase in le#tventricular diastolic pressure and ma4ing 6ph-siologicall- stenotic


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Natural HistoryNatural History

"ts ith Acute A$ have poor prognosisithout intervention

"ts ith evere chronic A$ in 89 A classIII I have an annual mortalit- o# ;'

"ts ith evere chronic A$ in 89 A classII have an annual mortalit- o#


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Natural HistoryNatural History

"ts as-mptomatic ith mar4ed 1 enlargment areassociated ith an increase ris4 ( ') o# suddendeath compared ith the general population

"ts as-mptomatic ithout 1 d-s#unction do nothave an- e3cess ris4 o# death as compared iththe general population, *ut do have highcardiovascular event rates (i/e/, heart #ailure, orne s-mptoms) at ; to < ' per -ear

8 Engl > 6ed ??%@=; : ;= !%


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DiagnosisDiagnosis

• Clinical e3amination• EC 2 . old tandard• T2E• C6$

• Angiogram• E3ercise Testing


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Echo assessment of AREcho assessment of AR

• Anatom-: Diameter o# annulus, o# alsalva , T>,

AA, Aneur-sm, Bicuspid-, 1 diameterF

• 6echanism: Dissection, Aneur-sm o# Aortic root, 1ea#let

prolapse, Endocarditis, Degenerative


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Echo assessment of AREcho assessment of AR

olodiastolic reversal #lo in the descending aorta

(. a*dominal aorta)/

0


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Timing of SurgeryTiming of Surgery


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Management Strategy forManagement Strategy forAortic RegurgitationAortic Regurgitation

http://content.onlinejacc.org/content/vol48/issue3/images/large/06014069.gr3.jpeg


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Surgical optionsSurgical options

• Aortic valve replacement6echanicalBioprostheticGBiological ( tentles 5 tented )

"ro*lem ith -ounger adult ptsassociated to anticoagulation andGor

prosthesis dura*ilit-

Henogra#t omogra#t Allogra#tBovine

"orcine E uine Cr-o omovital $oss


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Surgical optionsSurgical options

• Aortic alve repair

I# dura*le has the potential to *e a goodsolution in -ounger adult pts

l l f h


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Clinical anatomy of theClinical anatomy of theaortic rootaortic root

The aortic root is positioned to the right andpostirior relative to the su*pulmonar- in#undi*ulum


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+orming the out#lo tract #rom the 1 and its#unction is supporting structure #or the Aortic

alve, delineated superiol- *- the T> andin#eriorl- *- the A>

Devided in :

tructures distal to the attachments o# the

valvar lea#lets ( alvar inus)

tructures pro3imal to the attachments o# thevalvar lea#lets ( interlea#let or #i*rous triangles)


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The aortic root has *een opened through a longitudinal incision across the area o#aortic!mitral valvar continuit-, and spread open to sho the semilunar attachments o#the valvar lea#lets/ 8ote the interlea#let triangles e3tending to the sinutu*ular

7unction, and the crescents o# m-ocardium at the *ase o# the t o coronar- aortic

sinuses/


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The valve lea#lets are inserted into

the aortic all in a semilunar+ashion and their closuredetermined the valve competencein the central coaptation area@ the level o# the coaptation is at themiddle distance *et een the nadiro# their insertion and thecommissural areas

http://content.onlinejacc.org/content/vol48/issue3/images/large/06014069.gr3.jpeg


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Aortic Val e RepairAortic Val e RepairTechni ues o# aortic valve repair have *een documented #or over %? -ears/

tarr and associates #irst reported a techni ue #or aortic repair in


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The functional classification of aortic rootThe functional classification of aortic roota!normalitiesa!normalities

responsi!le for aortic insufficiencyresponsi!le for aortic insufficiency

+unctional classi#ication o# aortic rootGvalve a*normalities and their correlation ithetiologies and surgical procedures El Mhour- et All Curr 2pin Cardiol/ ??;6ar@ ?( ): ;! / Department o# Cardiovascular and Thoracic urger-, Clini uesNniversitaires aint!1uc, Brussels, Belgium /


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The functional classification of aortic rootThe functional classification of aortic roota!normalitiesa!normalities

responsi!le for aortic insufficiencyresponsi!le for aortic insufficiency

The aim o# this classi#icationis to provide a simpleguide in the diagnosis o#ma7or a*normalities sothat corrective surgicaltechni ues can then *eapplied to each identi#ied

a*normalit-


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Surgical proceduresSurgical procedures

T-pe Ia lesions are treated *-reduction o# thecircum#erence o# the Sino8tubular 9unction and isusually achieved byreplacin the ascendinaorta with anappropriately si:ed

Dacron raft. ;deally, its dia eter

should be appro dilation)


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T-pe I* lesions are treated *- an aortic valve sparing operation,the remodeling techni ue (9acou*) and the reimplantation

techni ue (David operation)

$emodeling o# the aortic root $eimplantation o# the aortic valve ith creation o# neo!aortic sinuses

T-pe I*: pro3imal (valsalva sinuses) dilation and T> dilation


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+or the T-pe Ic the most appropriate surgical procedurema- *e a partial su*!commissural annuloplast- or circular

annuloplast-

Circular Annuloplast-

T-pe Ic: isolated +AA dilation

Commissural Annuloplast-


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Surgical proceduresSurgical proceduresT-pe Id: cusp per#oration and +AA dilation

Type ;d lesions aretreated by patch

closure.+or large de#ectsautologous tricuspidlea#let tissue is usedrather than autologouspericardium in the hopethat ill remain #ree #romcalci#ication

http://www.ctsnet.org/graphics/experts/Adult/mckellar/figure_4.gif


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Surgical proceduresSurgical proceduresT-pe II Cusp prolapse:

1" repair ith central plication/ The normal #ree margin ta4en as re#erence "lication ise3tended ith a short running suture, perpendicular to the #ree margin, %O; mm through

the *od- o# the lea#let in order to decrease lea#let distension

lea#let plication ("1)

http://www.ctsnet.org/graphics/experts/Adult/mckellar/figure_3.gif


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Surgical proceduresSurgical proceduresT-pe II Cusp prolapse ore!Te3 resuspension ( T3)

$esuspension ith running suture o# ore!Te3 &G?/ The &G? ore!Te3 suture is passed

t ice in the top o# the commissure/

uccessivel-, t o running sutures arepassed over and over around the length o#the #ree margin

With gentle traction on each *rancho# the ore!Te3 sutures and appl-ingopposite resistance ith a #orceps the #reemargin is shortened *- slightl- rin4ling thetissue


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Surgical proceduresSurgical proceduresT-pe II Cusp prolapse:The triangular resection

The triangular resection involves e3cising atriangle o# tissue in the middle o# theprolapsing valve and then suturing theedges *ac4 together/

A continuous suture is recommendedinstead o# interrupted sutures *ecause itdecreases the chance o# a lea4 andlessens throm*ogenicit-


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Surgical proceduresSurgical proceduresT-pe III $estrictive Cuspid motion

having, decalci#icationand valve e3tension ithThree strips o#pericardium, =5K mm thatare se n to the #ree

edges o# the valve cuspsto e3tend them andincrease the sur#ace area#or coaptation


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Results" The #russels E$perienceResults" The #russels E$perience

El Mhour- et All Curr 2pin Cardiol/ ??; 6ar@ ?( ): ;! /


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El Mhour- et All Curr 2pin Cardiol/ ??; 6ar@ ?( ): ;! /


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Actuarial survival curves/ (a) +reedom #rom A$ grade P in su*groups o# patientshaving lea#let plication ("1), ore!Te3 resuspension ( T3) or the com*ination o#"1 0 T3 and (*) #reedom #rom A$ grade P in su*groups o# patients havingtriangular resection (T$) or pericardial patch repair ("") alone or in com*ination

ith T3


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$esult A paring ith A $epair $esult A paring ith A $epair

(a) Actuarial survival curve. (b) curve for freedom from recurrence ofaortic regurgitation exceeding grade 2 or stenosis (including early andlate recurrences)

ebrin *l 7houry et All Ann )horac 'urg (##1%83&'146 2"

8 . %< pts


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ResultsResults

ResultsResults


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ResultsResults

ResultsResults


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ResultsResults

Aortic valve repair #or aortic insu##icienc- in adults: a contemporar- revie and comparison ithreplacement techni ues 2ohn Alfred -arra, =dward . Sava ea,b,> European >ournal o# Cardio!thoracic urger- ; ( ??%)


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DisDis cussioncussion

The optimal treatment o# aorticinsu##icienc- ould *e to replace orrepair the valve to its pre!diseasestate, ithout the need #or long!termanticoagulation and o*tain li#e!longdura*ilit-/

Currentl-, no such treatment e3ists/


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DisDis cussioncussion

The ris4 o# throm*oem*olism and in#ectious endocarditis is roughl- e uivalent

The dura*ilit- #or valve repair seem less #avora*le than *ioprosthetic replacement/( di##icoult comparison, Biopro mean age & , repair mean age =< )

=arly durability of aortic valve repair is si ilar to that of pul onary

auto raft, or ho o raft replace ent valve in youn er people, but laterdurabilit is worse


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ConclusionConclusion• $epair ma- not *e 7usti#ied in older patients ith e3cellent

proven longevit- o# *ioprostheses/

• Bicuspid valves ma- *e less amena*le to reparative techni ues than tricuspid valves, *ecause the calci#ication in

the bicuspid valve is ore di?use fro free ar in toaortic wall

@ atients with rheu atic valvular disease appear to havean

increased incidence of recurrence and repair failure.


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ConclusionConclusion

• alve repair ma- *e an option in care#ull-selected patients, in particular in association ithprocedure li4e valve!sparing

@Valve repair is an established part of thetreat ent ar a entariu for aorticvalvular disease but is a techniBue inevolution, reBuirin better deCnition ofsuccessful approaches.


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Than4 9ouThan4 9ou

aortic regurgitation and aorti repair ii

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