Transcript Aortic Regurgitation and Aoortic Valve Repair - Area

Aortic Regurgitation and
Aortic Leaflet Repair
Cesare Quarto MD
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 mmM2 of BSA
• LVESD - 46 mm or 27 mmM2 of BSA
• Ejection fraction - 51%
How should this patient be treated?
Cause of AR
• Developing Countries: rheumatic disease
• Western Countries
Congenital (Bicuspid
Valve)
Degenerative
(annulo-ectasia)
• In rare cases, aortic regurgitation is acute
(Endocarditis, Aortic Dissection, Trauma)
Aortic Regurgitation
Prevalence of AR is 4-7% of the population
prevalence with age
Severe regurgitation
women
( Framingham Heart Study)
observed in men than
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
Symptoms
Left sided heart failure:
Dyspnoea, orthopnoea, fatigue, paroxysmal
nocturnal dyspnoea
Syncope and Angina due to reduced aortic
diastolic BP
Occasionally carotid artery pain
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
physiologically stenotic
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%
N Engl J Med 2004;351:1539-46. Aortic Regurgitation,Maurice
Enriquez-Sarano et All.
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
N Engl J Med 2004;351:1539-46. Aortic Regurgitation,Maurice
Enriquez-Sarano et All.
Diagnosis
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Clinical examination
ECHO = Gold Standard
TOE
CMR
Angiogram
Exercise Testing
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
Echo assessment of AR
+
Holodiastolic reversal flow in the descending aorta
(= abdominal aorta).
Timing of Surgery
Management Strategy for
Aortic Regurgitation
Surgical options
• Aortic valve replacement
Mechanical
Bioprosthetic/Biological (Stentles – Stented)
Bovine
Porcine
Xenograft Homograft
Equine Cryo
Allograft
Homovital
Ross
Problem with younger adult pts
associated to anticoagulation and/or
prosthesis durability
Surgical options
• Aortic Valve repair
If durable has the potential to be a good
solution in younger adult pts
Clinical anatomy of the
aortic root
The aortic root is positioned to the right and
postirior relative to the subpulmonary infundibulum
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)
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
junction, and the crescents of myocardium at the base of the two coronary aortic
sinuses.
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
commissural areas
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
.
[3] Trusler GA, Moes CAF, Kidd BSL. Repair of ventricular septal defect with aortic insufficiency. J Thorac Cardiovasc Surg
1973;66: 394–403.
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.
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
Surgical procedures
Type Ia: distal ascending aorta dilation, (STJ dilation)
Type Ia lesions are treated
by reduction of the
circumference of the Sinotubular 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
Surgical procedures
Type Ib: proximal (valsalva sinuses) dilation and STJ dilation
Remodeling of the aortic root
Reimplantation of the aortic valve with creation of neo-aortic sinuses
Type Ib lesions are treated by an aortic valve sparing operation,
the remodeling technique (Yacoub) and the reimplantation
technique (David operation)
Surgical procedures
Type Ic: isolated FAA dilation
Circular Annuloplasty
Commissural Annuloplasty
For the Type Ic the most appropriate surgical procedure
may be a partial sub-commissural annuloplasty or circular
annuloplasty
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
Surgical procedures
Type II Cusp prolapse: leaflet plication (PL)
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 the body of the leaflet in order to decrease leaflet distension
Surgical procedures
Type II Cusp prolapse Gore-Tex resuspension (GTx)
Resuspension with running suture of GoreTex 7/0. The 7/0 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
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
lessens thrombogenicity
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
Results: The Brussels Experience
El Khoury et All Curr Opin Cardiol. 2005 Mar;20(2):115-21.
Results: The Brussels Experience
El Khoury et All Curr Opin Cardiol. 2005 Mar;20(2):115-21.
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
with GTx
Result AV Sparing with AV Repair
N =146 pts
(a) Actuarial survival curve. (b) curve for freedom from recurrence of
aortic regurgitation exceeding grade 2 or stenosis (including early and
late recurrences)
Gebrin El Khoury et All Ann Thorac Surg 2007;83:S746 –51
Results
Results
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
Discussion
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.
Currently, no such treatment exists.
Discussion
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 )
Early durability of aortic valve repair is similar to that of pulmonary autograft, or
homograft replacement valve in younger people, but later durability is worse
Conclusion
• Repair may not be justified in older patients with excellent
proven longevity of bioprostheses.
• Bicuspid valves may be less amenable to reparative
techniques than tricuspid valves, because the calcification in
the bicuspid valve is more diffuse from free margin to aortic wall
• Patients with rheumatic valvular disease appear to have an
increased incidence of recurrence and repair failure.
Conclusion
• Valve repair may be an option in carefully
selected patients, in particular in association with
procedure like valve-sparing
• Valve repair is an established part of the
treatment armamentarium for aortic valvular
disease but is a technique in evolution, requiring
better definition of successful approaches.
Thank You