aortic root surgery decision making kriengchai prasongsukarn, md, msc

Aortic root surgeryAortic root surgeryDecision makingDecision making

Kriengchai Prasongsukarn, MD, MScKriengchai Prasongsukarn, MD, MSc

Case Case ผู้��หญิ�งไทย อาย� ผู้��หญิ�งไทย อาย� 25 25 ปี� ปี� underlying underlying Marfan’s syndrome, married, want to pregnantMarfan’s syndrome, married, want to pregnant

CXR:Dilatation of ascending aortaCXR:Dilatation of ascending aorta Echo/TEE: severe AR ,EF 70%,no RWMA, Echo/TEE: severe AR ,EF 70%,no RWMA,

dilated aortic root at sinus part of aorta 5.05 dilated aortic root at sinus part of aorta 5.05 cm, LVOT 2.4 cm, Ascending aortic dilate 5.6 cm, LVOT 2.4 cm, Ascending aortic dilate 5.6 cm indiametercm indiameter

Case 1Case 1

1.1. Tissue Valve/ Homograft ReplacementTissue Valve/ Homograft Replacement

2.2. Mechanical Valve ReplacementMechanical Valve Replacement

3.3. Composite valve graft (Bentall operation)Composite valve graft (Bentall operation)

4.4. Ross OperationRoss Operation

5.5. Aortic valve sparingAortic valve sparing

OperationOperation ? ?

Case Case ผู้��หญิ�งไทย อาย� ผู้��หญิ�งไทย อาย� 22 22 ปี�ปี� DX severe AS (DX severe AS (อาย� อาย� 19 19 ปี� ปี� ) s/p AV ) s/p AV

commissurotomy commissurotomy หลั�งท�าหลั�งท�า3 months 3 months มี�เหนื่��อยมี�เหนื่��อย ปีระมีาณ ปีระมีาณ 1-2 1-2 เดื�อนื่ หลั�งจากคลัอดืบุ�ตรคนื่แรกผู้��เดื�อนื่ หลั�งจากคลัอดืบุ�ตรคนื่แรกผู้��

ปี$วยเหนื่��อยมีากขึ้'(นื่ ตรวจพบุว*ามี� ปี$วยเหนื่��อยมีากขึ้'(นื่ ตรวจพบุว*ามี� severe AR, severe AR, ผู้��ผู้��ปี$วยมีาปีร'กษาแพทย,ว*าถ้�าหลั�งจากการผู้*าต�ดืแลั�ว ปี$วยมีาปีร'กษาแพทย,ว*าถ้�าหลั�งจากการผู้*าต�ดืแลั�ว ผู้��ปี$วยย�งอยากท��จะมี�บุ�ตรต*อผู้��ปี$วยย�งอยากท��จะมี�บุ�ตรต*อ

Case 2Case 2

Echo: EF 62%, Severe AR (regurgitation flow Echo: EF 62%, Severe AR (regurgitation flow 1114 ms., PHT 323 ms.), tricuspid and torn 1114 ms., PHT 323 ms.), tricuspid and torn leaflet, no calcificationleaflet, no calcification

Case 2Case 2

Case Case ผู้��ชายไทยอาย� ผู้��ชายไทยอาย� 21 21 ปี� ปี� severe AR severe AR ผู้��ปี$วยมีาผู้��ปี$วยมีาปีร'กษาแพทย, เร��องการผู้*าต�ดืว*า หลั�งการผู้*าต�ดืผู้��ปีร'กษาแพทย, เร��องการผู้*าต�ดืว*า หลั�งการผู้*าต�ดืผู้��ปี$วยไมี*ขึ้อ ปี$วยไมี*ขึ้อ on anticoagulant on anticoagulant

Echo: EF 61%, severe AR (PHT 128-150 ms.), Echo: EF 61%, severe AR (PHT 128-150 ms.), LVEDD 65 mm, LV enlargement, Aortic LVEDD 65 mm, LV enlargement, Aortic annulus 2.75 cm., Pulmonic valve 2.61-2.69 annulus 2.75 cm., Pulmonic valve 2.61-2.69 cm., Aortic Valve are trileaflets, retracted and cm., Aortic Valve are trileaflets, retracted and rolling.rolling.

Case 3Case 3

Case Case ผู้��ชายไทย อาย� ผู้��ชายไทย อาย� 24 24 ปี� มีาดื�วย ไขึ้� เหนื่��อยปี� มีาดื�วย ไขึ้� เหนื่��อย Dx:BE with severe AR, Dx:BE with severe AR, ร�กษาไดื� ร�กษาไดื� ATB ATB ครบุ ครบุ 6 wk6 wk คลั�าไดื�ก�อนื่ท��บุร�เวณก�นื่ดื�านื่ซ้�ายคลั�าไดื�ก�อนื่ท��บุร�เวณก�นื่ดื�านื่ซ้�าย(AVM at left (AVM at left

buttock)buttock) Echo:Severe AR, EF 60%, Aortic root 28.8 mm, Echo:Severe AR, EF 60%, Aortic root 28.8 mm,

sinotubular junction 28 mm, aortic root 24.8 mm, sinotubular junction 28 mm, aortic root 24.8 mm, tricuspid AV, vegetation size 24x9.9 mm tricuspid AV, vegetation size 24x9.9 mm attached to left cuspattached to left cusp and down to septum, and down to septum, pulmonic valve 24. mmpulmonic valve 24. mm

Case 4Case 4

Case Case ผู้��ชายไทย อาย� ผู้��ชายไทย อาย� 40 40 ปี� มีาดื�วยเหนื่��อยมีากขึ้'(นื่ขึ้ณะปี� มีาดื�วยเหนื่��อยมีากขึ้'(นื่ขึ้ณะสอนื่หนื่�งส�อสอนื่หนื่�งส�อ

CXR: Dilatation of of ascending aortaCXR: Dilatation of of ascending aorta CTA: Aortic aneurysm at ascending aorta size 6.2 CTA: Aortic aneurysm at ascending aorta size 6.2

cm in diameter.cm in diameter. Echo: moderate AR, EF 48%, ascending aortic Echo: moderate AR, EF 48%, ascending aortic

aneurysm 6 cm in diameter, no evidence of aneurysm 6 cm in diameter, no evidence of ascending aortic dissection, LVOT 4.2 cm, STJ 5.2 ascending aortic dissection, LVOT 4.2 cm, STJ 5.2 cm, tubular diameter 4.2 cm, AV 3 leaflets, no cm, tubular diameter 4.2 cm, AV 3 leaflets, no MR/MSMR/MS

Case 5Case 5

femalefemale 59 years old, chest pain, FC III59 years old, chest pain, FC III CXR: Dilatation of of ascending aortaCXR: Dilatation of of ascending aorta Echo: moderate AR, EF 39%, ascending aortic Echo: moderate AR, EF 39%, ascending aortic

aneurysm 5 cm in diameter, no evidence of aneurysm 5 cm in diameter, no evidence of ascending aortic dissection, sinus valsava 6 ascending aortic dissection, sinus valsava 6 cm, AV 3 leaflets rolling and retracted of cm, AV 3 leaflets rolling and retracted of leaflets, mild MRleaflets, mild MR

Case 6Case 6

Tissue valveTissue valve

AVR - Hancock II Bioprosthesis AVR - Hancock II Bioprosthesis from TGHfrom TGH

670 patients670 patients Mean age: 65+/-12 years (range 18 to 87)Mean age: 65+/-12 years (range 18 to 87) Sex: male - 75%Sex: male - 75%

female - 25%female - 25% ECG: sinus - 92%ECG: sinus - 92%

AF - 8%AF - 8% Previous AVR - 10%Previous AVR - 10%

AVR - Hancock II BioprosthesisAVR - Hancock II Bioprosthesis

NYHA functional class I - 3%NYHA functional class I - 3%

II - 23%II - 23%

III - 43%III - 43%

IV - 31%IV - 31% AV lesion: AS - 46%AV lesion: AS - 46%

AI - 25%AI - 25%

Mixed - 29%Mixed - 29%


Infective endocarditis: Active - 24 ptsInfective endocarditis: Active - 24 pts

Healed - 11 ptsHealed - 11 pts Coronary artery disease: 297 pts (44%)Coronary artery disease: 297 pts (44%) Ascending aortic aneurysm: 73 pts (11%)Ascending aortic aneurysm: 73 pts (11%) Left ventricular EF: Left ventricular EF: >>40% - 428 pts (64%)40% - 428 pts (64%)

<40% - 143 pts (21%)<40% - 143 pts (21%)

N.A. - 99 pts (15%)N.A. - 99 pts (15%)


Operative Data:Operative Data: Valve size: #21 = 48 pts (7%)Valve size: #21 = 48 pts (7%) #23 = 198 pts (30%)#23 = 198 pts (30%) #25 = 208 pts (31%)#25 = 208 pts (31%) #27 = 174 pts (26%)#27 = 174 pts (26%) #29 = 42 pts (6%) #29 = 42 pts (6%) Aortic annulus enlargement: 125 pts (19%)Aortic annulus enlargement: 125 pts (19%)

#21=24 pts; #23=53 pts; #25=58 pts #21=24 pts; #23=53 pts; #25=58 pts


Operative mortality - 32 pts (5%)Operative mortality - 32 pts (5%) Operative morbidity:Operative morbidity:

Bleeding/tamponade - 33 (5%)Bleeding/tamponade - 33 (5%)

Myocardial infarction - 9 (1.3%)Myocardial infarction - 9 (1.3%)

Stroke/TIA - 22 (3.2%)Stroke/TIA - 22 (3.2%)

Sternal infection - 4 (0.6%)Sternal infection - 4 (0.6%)

Early endocarditis - 2 (0.3%)Early endocarditis - 2 (0.3%)


Follow-up: 86+/-45 mo. (range 0 - 200)Follow-up: 86+/-45 mo. (range 0 - 200)

99% complete99% complete Deaths: Total - 237 (35.3%)Deaths: Total - 237 (35.3%)

Operative - 32 (13.5%) Operative - 32 (13.5%)

Valve-related - 28 (12%)Valve-related - 28 (12%)

Cardiac-related - 81 (34%)Cardiac-related - 81 (34%)

Other causes - 96 (40.5%) Other causes - 96 (40.5%)

Hancock II: AVRHancock II: AVRSurvivalSurvival

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

10

20

30

40

50

60

70

80

90

100

Years Postoperatively

Su

rviv

al (

%)

47 ± 3%

610 567 482 360 208 116 43 18

Patients @ Risk

Hancock II: AVRHancock II: AVRFree From Structural Valve Free From Structural Valve

DysfunctionDysfunction

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

10

20

30

40

50

60

70

80

90

100


Fre

e F

rom

SV

D (

%)

81 ± 5%

610 570 481 360 208 116 43 18

Patients @ Risk

Hancock II: AVRHancock II: AVRFree From Structural Valve DysfunctionFree From Structural Valve Dysfunction

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

102030405060708090

100


Fre

e F

rom

SV

D (

%)

<65 yr >=65 yr

99.6 ± 0.4%

Patients @ Risk377233

347223

285196

198162

96111

44 72

11 32

711

72 ± 7%

P<0.001

>=65<65

Hancock II: AVRHancock II: AVRFree From ReoperationFree From Reoperation

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 150

10

20

30

40

50

60

70

80

90

100


Fre

e F

rom

Reo

per

atio

n (

%)

77 ± 5%

610 570 481 360 208 116 43 18

Patients @ Risk

AVR: Hancock II BioprosthesisAVR: Hancock II BioprosthesisSummary of EventsSummary of Events

5yr 10yr 15yr5yr 10yr 15yr

Freedom from:Freedom from:

Death 79% 61% 47%Death 79% 61% 47%

Thromboembolism 95% 87% 83%Thromboembolism 95% 87% 83%

Endocarditis 98% 97% 96%Endocarditis 98% 97% 96%

Tissue failure 100% 97% 81%Tissue failure 100% 97% 81%

Reoperation 98% 94% 77% Reoperation 98% 94% 77%

AVR: CE PerimountAVR: CE Perimount

CE PerimountCE Perimount

No. Patients 310No. Patients 310Mean Age +/-S.D. 65+/-12Mean Age +/-S.D. 65+/-12NYHA class IV 33% NYHA class IV 33% Coronary artery disease 41%Coronary artery disease 41%

Banbury et al - Ann Thorac Surg – 2001;72:753Banbury et al - Ann Thorac Surg – 2001;72:753

AVR with CE PerimountAVR with CE PerimountFreedom from FailureFreedom from Failure

0102030405060708090

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Years

Per

cent

fre

e

15 yr = 77%

Banbury et al - Ann Thorac Surg – 2001;72:753

The Journal of Thoracic and Cardiovascular Surgery October 2005

Carpentier-Edwards supra-annular aortic porcine bioprosthesis: Clinical performance over 20 years

W.R.Eric Jamieson and colleagues

AV Bioprostheses: Freedom from Tissue Failure

Pt’s age 15 years

Hancock II David et al 65±11 81% Rizolli et al 67±8 89%

CE Perimount Banbury et al 65±12 77% Neville et al 68±11 94% (12yr) Frater et al 65±12 85% (14yr)

SJM Biocor 69 76%CE porcine 69 75%

AV BioprosthesesAV BioprosthesesFreedom from FailureFreedom from Failure

Jamieson’s discussionJamieson’s discussion

““There is no apparent difference in failure rates There is no apparent difference in failure rates of second generation porcine valves and CE of second generation porcine valves and CE Perimount…”Perimount…”

HomograftHomograft

AVR with Aortic Valve HomograftAVR with Aortic Valve Homograft

Versatile: Versatile: Sub-coronary implantationSub-coronary implantation

Aortic root inclusionAortic root inclusionAortic root replacementAortic root replacement

Excellent flow characteristics, particularly when Excellent flow characteristics, particularly when used as an aortic root replacement deviceused as an aortic root replacement device

Drawbacks: Drawbacks: Limited availability Limited availability

Limited durabilityLimited durability

Durability of Aortic Valve Homograft

AVR with Aortic Valve HomograftAVR with Aortic Valve HomograftFreedom from ReoperationFreedom from Reoperation

0102030405060708090

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Years

Per

cent

fre

e

Pts at risk546 450 148 12

10 year = 87%15 year = 76%

Pts’ mean age = 47 yrs

O’Brien et al. J Heart Valve Dis 2001;10:334


Freedom from reoperation Freedom from reoperation Freedom from failure Freedom from failure

AVR with Aortic Valve HomograftAVR with Aortic Valve HomograftFreedom from Reoperation & FailureFreedom from Reoperation & Failure

0

20

40

60

80

100

0 2 4 6 8 10 12 14 16 18 20

Years

Per

cent

fre

e

Freedom from reoperation Freedom from failure

Lund et al. J Thorac Cardiovasc Surg 1999;117:77

Freedom from Reoperation Failure 10-year 81% 65% 20-year 62% 18%


Drawbacks:Drawbacks: Limited availabilityLimited availability Limited durabilityLimited durability Complicated reoperation: high op mortalityComplicated reoperation: high op mortality Better than xenografts?Better than xenografts?

Stentless valveStentless valve

AVR with Medtronic FreestyleAVR with Medtronic FreestyleFreedom from ReoperationFreedom from Reoperation

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10

Years

Per

cent

fre

e

Bach et al. – Ann Thorac Surg 2005;80:480

10 yr = 92%

Pts at risk488 346 305 218 118 30

AVR with Medtronic FreestyleAVR with Medtronic FreestyleFreedom from Moderate/Severe AIFreedom from Moderate/Severe AI

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10

Years

Per

cent

fre

e

Sub-coronary Root replacement

10-year:Sub-coronary = 87%Root replaced = 98%

Bach et al. – Ann Thorac Surg 2005;80:480

Pts’ mean age = 72 years

AV Homograft vs. Medtronic FreestyleAV Homograft vs. Medtronic Freestyle

Medina et al. Medina et al. Three-dimensional in vivo characterization of Three-dimensional in vivo characterization of calcification in native valves and in Freestyle versus calcification in native valves and in Freestyle versus homograft aortic valveshomograft aortic valves

J Thorac Cardiovasc Surg 2005;130:41J Thorac Cardiovasc Surg 2005;130:41

Quantitative evaluation of calcium deposits in the aortic valve Quantitative evaluation of calcium deposits in the aortic valve by electron beam tomography data fusion technique:by electron beam tomography data fusion technique:

Freestyle had lower amounts of calcium than aortic valve Freestyle had lower amounts of calcium than aortic valve homograft 2 years after implantationhomograft 2 years after implantation

Choice of Valve in Active Infective Choice of Valve in Active Infective Endocarditis of the Aortic ValveEndocarditis of the Aortic Valve

Conventional wisdomConventional wisdom

Aortic valve homograft is the best valve to Aortic valve homograft is the best valve to treat patients with active infective treat patients with active infective endocarditis, particularly if an abscess is endocarditis, particularly if an abscess is presentpresent

Aortic Root Replacement with Aortic Root Replacement with Aortic Valve HomograftAortic Valve Homograft

1989-20031989-2003 213 patients213 patients Mean age: 51 yearsMean age: 51 years Indication for surgery:Indication for surgery:

73 – Native AV endocarditis73 – Native AV endocarditis 52 – Prosthetic AV endocarditis52 – Prosthetic AV endocarditis All 213 patients had aortic root replacementAll 213 patients had aortic root replacement Operative mortality 16/213 (7.5%)Operative mortality 16/213 (7.5%) Kaya et al. – Ann Thorac Surg 2005;79:1491

58%


Freedom from adverse events (survivors only):Freedom from adverse events (survivors only):

5-year 10-year5-year 10-yearFreedom from death Freedom from death 87% 71% 87% 71%Freedom from reoperation 94% 76%Freedom from reoperation 94% 76%

Kaya et al. – Ann Thorac Surg 2005;79:1491


Reasons for reoperation: 20/194Reasons for reoperation: 20/194 12 – Homograft failure12 – Homograft failure

3 – False aneurysm3 – False aneurysm 3 – Endocarditis in the homograft3 – Endocarditis in the homograft

3 – Other reasons3 – Other reasons Reoperation mortality: 25%Reoperation mortality: 25% Endocarditis in the homograft: 4 casesEndocarditis in the homograft: 4 cases

Kaya et al. – Ann Thorac Surg 2005;79:1491

Aortic Valve Homograft for Aortic Valve Homograft for Aortic Root AbscessAortic Root Abscess

1987-2003: 161 patients1987-2003: 161 patients 78 sub-coronary implantation78 sub-coronary implantation 83 aortic root replacement83 aortic root replacement 83 aorto-ventricular discontinuity 83 aorto-ventricular discontinuity 81 prosthetic valve endocarditis 81 prosthetic valve endocarditis Operative mortality: 9.3% urgent; 14.3% emergentOperative mortality: 9.3% urgent; 14.3% emergent 11 early reoperations for dehiscence/infection 11 early reoperations for dehiscence/infection 73% free from reoperation at 10 years73% free from reoperation at 10 years

Yankah et al - Eur J Cardio-Thorac Surg 2005;28:69

Aortic Valve Surgery for Aortic Valve Surgery for Active Infective EndocarditisActive Infective Endocarditis

Infection limited to valve cusps Infection limited to valve cusps

= simple AVR= simple AVR

Infection extended into paravalvular tissues Infection extended into paravalvular tissues = radical resection of all seemingly = radical resection of all seemingly

infected tissues and reconstruction with infected tissues and reconstruction with appropriate patchesappropriate patches

Surgery for Active Infective Surgery for Active Infective EndocarditisEndocarditis

Experience at Toronto General HospitalExperience at Toronto General Hospital

418 patients418 patients Mean age: 52Mean age: 52±16 years±16 years Sex: 65% maleSex: 65% male Native valve: 287 (68%)Native valve: 287 (68%) Prosthetic valve: 131 (32%)Prosthetic valve: 131 (32%) Paravalvular abscess: 150 (36%)Paravalvular abscess: 150 (36%)



Operations performedOperations performed 268 replacement/repair of one (212 patients) or two or more 268 replacement/repair of one (212 patients) or two or more

valves (56 patients)valves (56 patients)

NO aortic homograft usedNO aortic homograft used 150 reconstruction of annulus + valve replacement of one (88 150 reconstruction of annulus + valve replacement of one (88

patients) or two or more valves (62 patients)patients) or two or more valves (62 patients)

18 aortic homograft used18 aortic homograft used Mechanical valves in 42%; tissue valves in 55%; valve repair Mechanical valves in 42%; tissue valves in 55%; valve repair

alone in 3%alone in 3%



Operative mortality: 11.5%Operative mortality: 11.5%Predictors: Odds ratioPredictors: Odds ratio Shock Shock 5.25.2

Prosthetic valve Prosthetic valve 3.23.2Preop renal failurePreop renal failure 2.32.3

(Surgeon was a predictor of operative mortality in patients with (Surgeon was a predictor of operative mortality in patients with prosthetic valve and/or abscess)prosthetic valve and/or abscess)


SurvivalSurvival

0102030405060708090

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Years

Per

cent

livi

ng

5 year = 74%10 year = 63%15 year = 45%

Pts at risk418 279 134 29


Survival: Valve vs. Abscess Survival: Valve vs. Abscess

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Years

Per

cent

livi

ng

abscess valve

1 year 15 yearValve 87% 50%Abscess 81% 39%


Freedom from Recurrent EndocarditisFreedom from Recurrent Endocarditis

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Years

Per

cent

livi

ng

Pts at risk418 279 134 29

5 year = 93%10 year = 88%15 year = 86%


Freedom from ReoperationFreedom from Reoperation

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Years

Per

cent

livi

ng

Pts at risk418 279 134 29

5 year = 97%10 year = 91%15 year = 71%

Surgery for Active Infective Surgery for Active Infective EndocarditisEndocarditisConclusionsConclusions

Continues to be associated with high operative Continues to be associated with high operative mortality and morbidity, particularly in patients with mortality and morbidity, particularly in patients with aortic root abscessaortic root abscess

Radical resection of all infected tissues is probably Radical resection of all infected tissues is probably more important than the valve implanted as far as the more important than the valve implanted as far as the chances of curing the endocarditis chances of curing the endocarditis

ConclusionsConclusionsHomograftHomograft

AV homograft offers no advantage over xenograft AV homograft offers no advantage over xenograft valves in patients with aortic stenosisvalves in patients with aortic stenosis

AV homograft may be ideal for patients with AV homograft may be ideal for patients with infective endocarditis with paravalvular abscess but it infective endocarditis with paravalvular abscess but it is not a substitute for radical resection is not a substitute for radical resection

Homograft aortic root replacementHomograft aortic root replacement

More technically demanding (less rigid nature More technically demanding (less rigid nature of tissue)of tissue)

Recommended in age 40-60 yearsRecommended in age 40-60 years Study by McGiffin showed the unacceptably Study by McGiffin showed the unacceptably

high incidence of valve failure over 15 years high incidence of valve failure over 15 years periodperiod

McGiffin/ Grinda / Lytle found improved McGiffin/ Grinda / Lytle found improved freedom from recurrent endocarditis compared freedom from recurrent endocarditis compared with prosthetic material with prosthetic material

Pulmonary autograftPulmonary autograft

AVR with Pulmonary AutograftAVR with Pulmonary AutograftTGHTGH Experience (1990-2003) Experience (1990-2003)

213 patients213 patients 66% men66% men Mean age: 34 years (16 – 63 years)Mean age: 34 years (16 – 63 years) AV pathology:AV pathology:

82% - bicuspid/congenital82% - bicuspid/congenital

5% - prosthetic dysfunction5% - prosthetic dysfunction

2% - rheumatic2% - rheumatic

10% - miscellaneous10% - miscellaneous

AVR with Pulmonary AutograftAVR with Pulmonary Autograft

AV lesion: AS - 51% AV lesion: AS - 51%

AI - 36% AI - 36%

AS+AI - 13%AS+AI - 13% Follow-up: 6.1Follow-up: 6.1±3.4 years; 100% complete±3.4 years; 100% complete Annual echocardiographic studiesAnnual echocardiographic studies Annual visit to cardiologist and/or valve clinicAnnual visit to cardiologist and/or valve clinic

AVR with Pulmonary AutograftAVR with Pulmonary AutograftOperative OutcomeOperative Outcome

One operative death: AMIOne operative death: AMI 2 late deaths: 1 accident, 1 suicide2 late deaths: 1 accident, 1 suicide 11 patients had reoperations: (no death)11 patients had reoperations: (no death) 2 – false aneurysms (valve saved)2 – false aneurysms (valve saved)

5 – aortic insufficiency (valve replaced)5 – aortic insufficiency (valve replaced) 2 – pulmonary homograft stenosis 2 – pulmonary homograft stenosis 2 – coronary artery bypass2 – coronary artery bypass

17 patients developed moderate or severe AI17 patients developed moderate or severe AI 182 (85%) – free of any adverse event 182 (85%) – free of any adverse event

AVR with Pulmonary AutograftAVR with Pulmonary AutograftSurvival and Freedom from Any Survival and Freedom from Any

ReoperationReoperation

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12

Years

Per

cent

fre

e

Survival Freedom from reoperation

Pts at risk213 197 156 123 97 41 17

12-year:Survival = 98%Reop Free = 87%

AVR with Pulmonary AutograftAVR with Pulmonary AutograftFreedom from Aortic InsufficiencyFreedom from Aortic Insufficiency

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12

Years

Per

cent

fre

e

Free from 3+ & 4+ AI

Pts at risk213 197 156 123 97 41 17

12 yr = 88±4%

3+ AI = 12 patients4+ AI = 5 patients13/17 due to dilation

AVR with Pulmonary AutograftAVR with Pulmonary AutograftPredictors of Moderate or Severe AIPredictors of Moderate or Severe AI

Incompetent bicuspid aortic valveIncompetent bicuspid aortic valve

Odds ratio: 3.6Odds ratio: 3.6 Mismatch between aortic and pulmonary annuli >4 Mismatch between aortic and pulmonary annuli >4

mmmm

Odds ratio: 2.9Odds ratio: 2.9 Incompetent bicuspid aortic valve + mismatchIncompetent bicuspid aortic valve + mismatch

Odds ratio: 8.5Odds ratio: 8.5

AVR with Pulmonary AutograftAVR with Pulmonary AutograftFreedom from Moderate or Severe PI Freedom from Moderate or Severe PI ±± >40mmHg PS >40mmHg PS

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11 12

Years

Per

cent

fre

e

Free from PI/PS

Pts at risk213 197 156 123 97 41 17

12-yr = 86±4%

Age 34 years = 72%Age > 34 years = 100%

AVR with Pulmonary AutograftAVR with Pulmonary AutograftPredictors of Pulmonary Valve Predictors of Pulmonary Valve

Homograft DysfunctionHomograft Dysfunction

Patients’ age (by 5 years reductions)Patients’ age (by 5 years reductions)

Odds ratio 1.6Odds ratio 1.6 10 year freedom from PV dysfunction:10 year freedom from PV dysfunction:

<20 yr-old = 62%<20 yr-old = 62%±8%±8%

20-30 yr-old = 85%±5%20-30 yr-old = 85%±5%

>30 yr-old = 95%±2%>30 yr-old = 95%±2%

ResultResult

Factor for late AIFactor for late AI

MaleMale Aortic/ pulmonic annular mismatchAortic/ pulmonic annular mismatch Aortic annulus >= 27mmAortic annulus >= 27mm Preoperative AIPreoperative AI

Female, Aortic stenosis, annulus <27 mm got best outcomeNot recommended in bicuspid aortic valve, marfan syndrome, connective tissue disease

Ross ProcedureRoss Procedure

Very demanding technicallyVery demanding technically 80 % freedom from reoperation at 20 years80 % freedom from reoperation at 20 years Promise for IEPromise for IE David found dilatation of neoaortic valve in David found dilatation of neoaortic valve in

bicuspid aortic valve diseasebicuspid aortic valve disease Reserve for young patients who are not Reserve for young patients who are not

predisposed to aortic or pulmonary artery predisposed to aortic or pulmonary artery dilatation dilatation

ConclusionsConclusions Pulmonary Autograft Pulmonary Autograft

AVR with pulmonary autograft is probably the ideal AVR with pulmonary autograft is probably the ideal valve for young adults who are physically active and valve for young adults who are physically active and have aortic stenosishave aortic stenosis

Pulmonary autograft should be avoided in patients Pulmonary autograft should be avoided in patients with mismatch between the aortic and pulmonary with mismatch between the aortic and pulmonary annuli by more than 4 mm and/or an incompetent annuli by more than 4 mm and/or an incompetent bicuspid aortic valvebicuspid aortic valve

Composite valve graftComposite valve graft

Used in abnormal aortic cusp and dilated Used in abnormal aortic cusp and dilated aortic rootaortic root

Results varied as the indication of surgery Results varied as the indication of surgery (aortic dissection less than aneurysm)(aortic dissection less than aneurysm)

Mortality 5-10% Mortality 5-10% Freedom from TE93%Freedom from TE93% Freedom from endocarditis 90%Freedom from endocarditis 90% Freedom from reoperation 74% Freedom from reoperation 74%

CVG with tissue valveCVG with tissue valve

Results of CVGResults of CVG

Low operative MR (4-10%)Low operative MR (4-10%) Excellent long term survival (10 year survival Excellent long term survival (10 year survival

60%)60%) Freedom from TE, Endocarditis and Freedom from TE, Endocarditis and

Reoperation is goodReoperation is good

Aortic valve sparing Aortic valve sparing

30 % of Aortic root replacement has normal 30 % of Aortic root replacement has normal aortic valveaortic valve

Two technique: Remodeling (Yacoub)Two technique: Remodeling (Yacoub)

Reimplantation (David)Reimplantation (David)

(Less AI, good hemostasis, less reoperation, redo (Less AI, good hemostasis, less reoperation, redo for AVR easier)for AVR easier)

Aortic valve sparingAortic valve sparing

Indication are expanding to bicuspid aortic Indication are expanding to bicuspid aortic valve and type A dissectionvalve and type A dissection

Result (freedom from reoperation) is excellentResult (freedom from reoperation) is excellent

Remodeling (Yacoub technique)Remodeling (Yacoub technique)

Reimplantation (David technique)Reimplantation (David technique)

MR 0.6%15 year survival 87.8%15yrFreedom from AI 79.2%

Aortic Regurgitation

Congestive Heart Failure

Prominent Ascending Aortic Shadow

History

Physical ExaminationAChest x-ray

Echocardiogram

CT/MRI

B

Aortic Root Pathology

Mild-moderate AI

Size<5.0 cm

Severe AI

Size > 5.0 cm

Medical therapy

And follow-up

C

Aortic Root Replacement D

Age < 40 EAge 40-60 F Age > 60 G Extensive or

Prosthetic Valve

Endocarditis

Acute Type A

Aortic Dissection

Aorta not dilated Aorta dilated

Ross Procedure

Aortic valve

diseased

Aortic valve

not diseased

Mechanical CVG

Xenograft Root

Valve-Sparing

Root Replacement

Aortic valvediseased

Aortic valvenot diseased

Mechanical or

Tissue CVG

Homograft Root

Xenograft Root

Valve-Sparing

Root Replacement

Aortic valve

diseased

Tissue CVG

Xenograft Root

Aortic valve

not diseased

Valve-Sparing

Root Replacement

Homograft Root H

Aortic valve

diseased

Aortic valve

not diseased

Mechaical or Tissue

CVG

Separate Valve-Graft

Valve-Sparing Root

Replacement

I

John S. Ikonomidis, Aortic root replacement, in cardiac surgery

ConclusionConclusionType of surgery: depends onType of surgery: depends on

Patient conditionPatient condition

Age, comorbidity, condition of native aortic Age, comorbidity, condition of native aortic valve, pulmonic valve, limitation of valve, pulmonic valve, limitation of anticoagulant usage postopanticoagulant usage postop

Valve preference in each patientValve preference in each patient Surgeon (experience, skillful) Surgeon (experience, skillful)

Case Case ผู้��หญิ�งไทย อาย� ผู้��หญิ�งไทย อาย� 25 25 ปี� ปี� underlying underlying Marfan’s syndrome, married, want to pregnantMarfan’s syndrome, married, want to pregnant

CXR:Dilatation of ascending aortaCXR:Dilatation of ascending aorta Echo/TEE: severe AR ,EF 70%,no RWMA, Echo/TEE: severe AR ,EF 70%,no RWMA,

dilated aortic root at sinus part of aorta 5.05 dilated aortic root at sinus part of aorta 5.05 cm, LVOT 2.4 cm, Ascending aortic dilate 5.6 cm, LVOT 2.4 cm, Ascending aortic dilate 5.6 cm indiametercm indiameter

Case 1Case 1

Case Case ผู้��หญิ�งไทย อาย� ผู้��หญิ�งไทย อาย� 22 22 ปี�ปี� DX severe AS (DX severe AS (อาย� อาย� 19 19 ปี� ปี� ) s/p AV ) s/p AV

commissurotomy commissurotomy หลั�งท�าหลั�งท�า3 months 3 months มี�เหนื่��อยมี�เหนื่��อย ปีระมีาณ ปีระมีาณ 1-2 1-2 เดื�อนื่ หลั�งจากคลัอดืบุ�ตรคนื่แรกผู้��เดื�อนื่ หลั�งจากคลัอดืบุ�ตรคนื่แรกผู้��

ปี$วยเหนื่��อยมีากขึ้'(นื่ ตรวจพบุว*ามี� ปี$วยเหนื่��อยมีากขึ้'(นื่ ตรวจพบุว*ามี� severe AR, severe AR, ผู้��ผู้��ปี$วยมีาปีร'กษาแพทย,ว*าถ้�าหลั�งจากการผู้*าต�ดืแลั�ว ปี$วยมีาปีร'กษาแพทย,ว*าถ้�าหลั�งจากการผู้*าต�ดืแลั�ว ผู้��ปี$วยย�งอยากท��จะมี�บุ�ตรต*อผู้��ปี$วยย�งอยากท��จะมี�บุ�ตรต*อ

Case 2Case 2

Echo: EF 62%, Severe AR (regurgitation flow Echo: EF 62%, Severe AR (regurgitation flow 1114 ms., PHT 323 ms.), tricuspid and torn 1114 ms., PHT 323 ms.), tricuspid and torn leaflet, no calcificationleaflet, no calcification

Case 2Case 2

Case Case ผู้��ชายไทยอาย� ผู้��ชายไทยอาย� 21 21 ปี� ปี� severe AR severe AR ผู้��ปี$วยมีาผู้��ปี$วยมีาปีร'กษาแพทย, เร��องการผู้*าต�ดืว*า หลั�งการผู้*าต�ดืผู้��ปีร'กษาแพทย, เร��องการผู้*าต�ดืว*า หลั�งการผู้*าต�ดืผู้��ปี$วยไมี*ขึ้อ ปี$วยไมี*ขึ้อ on anticoagulant on anticoagulant

Echo: EF 61%, severe AR (PHT 128-150 ms.), Echo: EF 61%, severe AR (PHT 128-150 ms.), LVEDD 65 mm, LV enlargement, Aortic LVEDD 65 mm, LV enlargement, Aortic annulus 2.75 cm., Pulmonic valve 2.61-2.69 annulus 2.75 cm., Pulmonic valve 2.61-2.69 cm., Aortic Valve are trileaflets, retracted and cm., Aortic Valve are trileaflets, retracted and rolling.rolling.

Case 3Case 3

Case Case ผู้��ชายไทย อาย� ผู้��ชายไทย อาย� 24 24 ปี� มีาดื�วย ไขึ้� เหนื่��อยปี� มีาดื�วย ไขึ้� เหนื่��อย Dx:BE with severe AR, Dx:BE with severe AR, ร�กษาไดื� ร�กษาไดื� ATB ATB ครบุ ครบุ 6 wk6 wk คลั�าไดื�ก�อนื่ท��บุร�เวณก�นื่ดื�านื่ซ้�ายคลั�าไดื�ก�อนื่ท��บุร�เวณก�นื่ดื�านื่ซ้�าย(AVM at left (AVM at left

buttock)buttock) Echo:Severe AR, EF 60%, Aortic root 28.8 mm, Echo:Severe AR, EF 60%, Aortic root 28.8 mm,

sinotubular junction 28 mm, aortic root 24.8 mm, sinotubular junction 28 mm, aortic root 24.8 mm, tricuspid AV, vegetation size 14x9.9 mm tricuspid AV, vegetation size 14x9.9 mm attached to left cusp involve to septum, pulmonic attached to left cusp involve to septum, pulmonic valve 24. mmvalve 24. mm

Case 4Case 4

Case Case ผู้��ชายไทย อาย� ผู้��ชายไทย อาย� 40 40 ปี� มีาดื�วยเหนื่��อยมีากขึ้'(นื่ขึ้ณะปี� มีาดื�วยเหนื่��อยมีากขึ้'(นื่ขึ้ณะสอนื่หนื่�งส�อสอนื่หนื่�งส�อ

CXR: Dilatation of of ascending aortaCXR: Dilatation of of ascending aorta CTA: Aortic aneurysm at ascending aorta size 6.2 CTA: Aortic aneurysm at ascending aorta size 6.2

cm in diameter.cm in diameter. Echo: moderate AR, EF 48%, ascending aortic Echo: moderate AR, EF 48%, ascending aortic

aneurysm 6 cm in diameter, no evidence of aneurysm 6 cm in diameter, no evidence of ascending aortic dissection, LVOT 4.2 cm, STJ 5.2 ascending aortic dissection, LVOT 4.2 cm, STJ 5.2 cm, tubular diameter 4.2 cm, AV 3 leaflets, no cm, tubular diameter 4.2 cm, AV 3 leaflets, no MR/MSMR/MS

Case 5Case 5

femalefemale 59 years old, chest pain FC III59 years old, chest pain FC III CXR: Dilatation of of ascending aortaCXR: Dilatation of of ascending aorta Echo: moderate AR, EF 39%, ascending aortic Echo: moderate AR, EF 39%, ascending aortic

aneurysm 5 cm in diameter, no evidence of aneurysm 5 cm in diameter, no evidence of ascending aortic dissection, sinus valsava 6 ascending aortic dissection, sinus valsava 6 cm, AV 3 leaflets rolling and retracted of cm, AV 3 leaflets rolling and retracted of leaflets, mild MRleaflets, mild MR

Case 6Case 6



3.3. Composite valve graft with tissue valve Composite valve graft with tissue valve (Bentall operation)(Bentall operation)




aortic root surgery decision making kriengchai prasongsukarn, md, msc

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