anevrysme de l’aorte ascendant - cardiologie francophone · anevrysme tubulaire-stenose ,valve a...
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Anevrysme de l’aorte ascendantG .EL KHOURY
CLINIQUES ST LUC UCL BRUXELLES
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En fonction:-du segment aortique?
-racine aortique-aorte tubulaire (supra coronaire)
-de la dysfonction valvulaire?-stenose valvulaire,ou mal valv.-pure insuffisance aortique
-valve bicuspide
Anevrysme de l’aorte ascendant
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Anevrysme de l’aorte ascendant
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Anevrysme tubulaire
-stenose ,valve a remplacer
-insuffisance, valve a preserver?
Anevrysme de l’aorte ascendant
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Anevrysme tubulaire
-stenose ,valve a remplacer
Dilatation retro -stenotic
Anevrysme de l’aorte ascendant
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Anevrysme de l’aorte ascendantAge du patient:
• < 50 ans: -Ross
-mécanique
-biologique
• 50 à 65-70 ans : -mécanique
-biologique
• > 70 ans: -biologique
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Copyright ©2002 The American Association for Thoracic Surgery
Lewis, M. E. et al.; J Thorac Cardiovasc Surg 2002;123:573-575
No Caption Found
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Anevrysme tubulaire
-stenose ,valve a remplacer
-insuffisance, valve a preserver?
Anevrysme de l’aorte ascendant
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Aortic Sino-Tubular Ectasy: Ia – No AR
Aortic and Aortic and MitralMitral ReconstructiveSurgeryReconstructiveSurgery Symposium Symposium -- BrusselsBrussels-- 20042004
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Aortic Sino-Tubular Ectasy
Aortic and Aortic and MitralMitral ReconstructiveSurgeryReconstructiveSurgery Symposium Symposium -- BrusselsBrussels-- 20042004
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Aortic Sino-Tubular Ectasy
Aortic and Aortic and MitralMitral ReconstructiveSurgeryReconstructiveSurgery Symposium Symposium -- BrusselsBrussels-- 20042004
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Aortic Sino-Tubular Ectasy
Aortic and Aortic and MitralMitral ReconstructiveSurgeryReconstructiveSurgery Symposium Symposium -- BrusselsBrussels-- 20042004
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DAVID IV
DAVID
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Functionnal Aortic Annuloplasty
1/ Ventriculo-Aortic stabilization
Subcommissural annuloplasty with reinforced (teflon or autologuous pericardium) 2/0 sutures.
4th Aortic and 4th Aortic and MitralMitral Reconstructive Surgery Symposium Reconstructive Surgery Symposium -- BrusselsBrussels-- 20042004
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• AN. TUBULAIRE• +JET ECCENTRIC:• PROLAPSE
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• An.racine aortique
• Stenose valvulaire
• Pure ins.aortique
Anevrysme de l’aorte ascendant
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• An.racine aortique
– Stenose valvulaire
• Pure ins.aortique
Anevrysme de l’aorte ascendant
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• Freestyle implantation• Racine aortique • bentall
Anevrysme de l’aorte ascendant
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Anevrysme de l’aorte ascendant
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• An.racine aortique
• Stenose valvulaire
• Pure ins.aortique
Anevrysme de l’aorte ascendant
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Patients with aneurysm of the ascending aorta may have or not aortic regurgitation
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Aortic regurgitation in spite of the presence of normal or nearly normal aortic valve leaflets
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Conventional treatment = Composite replacement (Bentall)
Despite the success:
Complications = - T. Embolism- Endocarditis- Long-Term anticoagulation
� Impetus for the development of new surgical techniques
preserving the native aortic valve.
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+ + ValsalvaValsalva aneurysm aneurysm Aortic root remodelingAortic root remodeling
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ValsalvaValsalva aneurysm aneurysm Aortic root Aortic root reimplantationreimplantation+ dilated aortic annulus+ dilated aortic annulus
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Valve sparing operation :
Advantages : - Preserve the native valve- No need for anticoagulation- No thromboembolism- Resistance to infection
Disadvantages : - Abnormal valve tissue left behind
� Recurrence ? Durability ?
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The main issue:the durability of the preserved valve
--recurrence of AR:-yacoub:22% moderate AR(FU:3 Y)-david:25% severe AR(FU:10 Y)
--reoperation:-yacoub:17% at 10 years(pts at risk 10)-david: 0% at 8 years(pts at risk 9)
AORTIC VALVE SPARING SURGERY
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• Recurrence or occurrence of AR• patients selection,severity of AR,diseased
cusps,overstreched,fenestrations?• Preoperative missed or untreated cusp(s)
prolaps• Surgery related prolaps,post procedure• Not optimal coaptation,post procedure:level and
area of coaptation,• « zero tolerance »of residual AR,mainly if
eccentric jet
AORTIC VALVE SPARING SURGERY
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• Later on:• -aortic annulus dilatation?•• -cusp traumatism?(david operation)
• -endocarditis?
• -pseudoaneurysms
AORTIC VALVE SPARING SURGERY
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Anevrysme de l’aorte ascendant
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Anevrysme de l’aorte ascendant
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5th Symposium on A or tic a nd M itr a l R e c onstr uc tiv e Sur g e r y
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EarlyEarly ExperienceExperience withwith Valsalva Valsalva ProsthesisProsthesis
PATIENTS• 45 pts 04/2001 ⇒ 04/2005• Mean age 54 y ± 15• 80 % males• All elective surgery
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INDICATION FOR SURGERY• AR >II and/or Aorta Dilatation 98%
Mean Annulus: 25 ± 4 mm
Mean Sinus: 45 ± 6 mmMean STJ: 42 ± 7 mmMean Ascending Aorta: 51 ± 12 mm
• Other cardiac procedure 2 %
EarlyEarly ExperienceExperience withwith Valsalva Valsalva ProsthesisProsthesis
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PREOPERATIVE DATA
• AR >II 63%• Bicuspid valve 44%• Marfan Syndrome 5%• Previous cardiac surgery 5%
(2ROSS)• Mitral Valve Disease 9%• NYHA > II 24 %• CAD 2%• LEF >40% 94%
EarlyEarly ExperienceExperience withwith Valsalva Valsalva ProsthesisProsthesis
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SURGICAL TECHNIQUES (1)Results:
• Free margin reinforcement: 21 pts (47%)• Median raphe resection: 11 pts
(24%)• Radial plication: 10 pts (22%)
• Patch incorporation: 4 pts (9%)Tricuspid patch 2 pts (4%)
Pericardial patch 2 pts (4%)
• Triangular resection: 1 pt (2%)
EarlyEarly ExperienceExperience withwith Valsalva Valsalva ProsthesisProsthesis
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SURGICAL TECHNIQUES (2)Associated Procedures:
• MV repair 4 pts (9%)• Arch replacement 3 pts (7%)• PFO closure 2 pts (4%)• CABG 1 pt (2%)• Ross procedure 1 pt (2%)
EarlyEarly ExperienceExperience withwith Valsalva Valsalva ProsthesisProsthesis
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Results• Mean CCT 113 m (36-155)• Mean CPB 135 m (66-194) • Circulatory arrest 5 pts
EarlyEarly ExperienceExperience withwith Valsalva Valsalva ProsthesisProsthesis
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HOSPITAL EVENT (1)
•No mortality•Morbidity4 early reop : - 3 bleeding
- 1 sternal
EarlyEarly ExperienceExperience withwith Valsalva Valsalva ProsthesisProsthesis
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HOSPITAL EVENT (2)
Mean hospital stay 11 d ± 4Discharge echography:
No AR 32 pts (71%)AR grade I (central) 13 pts
(29%)
EarlyEarly ExperienceExperience withwith Valsalva Valsalva ProsthesisProsthesis
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LATE RESULTSMean Follow-up : 20 20 ±± 13m13mNo Late MortalityReoperation 1 pt (CABG)All survival in NYHA grade I-IIEchographic FU: No AR progression 40 pts
5 patients with AR grade II
EarlyEarly ExperienceExperience withwith Valsalva Valsalva ProsthesisProsthesis
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• Bicuspid aortic valve
• Stenose
• Insuffisance
• Racine aortique• Dilatee ou • non
Anevrysme de l’aorte ascendant
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Age du patient:
• < 50 ans: - Ross- mécanique- biologique
• 50 à 65-70 ans: - mécanique - biologique
• > 70 ans: - biologique
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• Some biscuspid entities
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G El Khoury MD, Vanoverschelde J-L MD Phd , D Glineur MD, A Poncelet MD, R Verhelst MD, P AstarciMD, JC Funken MD, J Rubay MD Phd, P Noirhomme
MD.
Cliniques Universitaires Saint-Luc Brussels-Belgium
DISCLOSURE INFORMATION:
No relationships exist related to this presentation
Bicuspid Aortic Valve Repairand Root Management
Mid Term Results
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• Aortic cusps• Aortic annulus• Valsalva sinuses• Commissures • Sinotubular junction
• ROOT PATHOLOGY
• CUSP PATHOLOGY (PROLAPSE)
AorticAortic RootRoot
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Functional type Lesions
Type 1 : normal cusp motion
1a : sino-tubular junction dilation 1b : ST junction + sinuses dilation 1c : annular dilation 1d : cuspal defect
Type 2 : cusp prolapse Excess of cuspal tissue Commissure flailed or distorted
Type 3 : restricted cusp motion
Fibrous thickening Calcifications
FunctionalFunctional classification classification ( ( TEE + Visual inspectionTEE + Visual inspection ))
Functianal classification of aortic root/valve abnormalities and their correlation with etiologiesand surgical procedures.
G. El Khoury, D Glineur, J Rubay et All Current Opinion in Cardiology 20:115-120. 2005
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AIM OF THE STUDY:
To report our experience in conservative surgery of regurgitant aortic bicuspid valve, isolated or associated to a dilatation of the aortic root and ascending aorta.
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PATIENTS:
• N : 68 pts 12/1995 ⇒ 11/2004
• Mean age : 43 y (16-76 y)
• ♂ : 65 (96%)
• NYHA > II : 42 pts (62%)
• Mean LVEF : 59 % ± 11
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INDICATION FOR SURGERY
• AR severity ( > 2) : 49%
• Aortic diameter : 53%
• Other cardiac procedure : 7%
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SURGICAL TECHNIQUES
• Leaflet pathology
• Root pathology
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• Some biscuspid entities
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StandardizedStandardized surgicalsurgical techniquetechnique
a)a) LeafletLeaflet pathologypathology : :
1) Adequation of the free margin length:- Plication- Resection- Patch incorporation
2) Reinforcement of the free margin (PTFE)
b)b) RootRoot managmentmanagment ::
1) without root dilatation :- Subcommissural annuloplasty- STJ plasty
2) with root dilatation :- Remodeling- Reimplantation
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Plication
Resection-suture
Raphe resectionPatch
incorporation
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StandardizedStandardized surgicalsurgical techniquetechnique
a)a) LeafletLeaflet pathologypathology ((prolapseprolapse) : ) :
1) Adequation of the free margin length:- Plication- Resection- Patch incorporation
2) Reinforcement of the free margin (PTFE)
b)b) RootRoot managmentmanagment ::
1) without root dilatation :- Subcommissural annuloplasty- STJ plasty
2) with root dilatation :- Remodeling- Reimplantation
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• Free margin reinforcement : - stabilisation of the repair- consolidation fragilised margin- adjust level coaptation
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StandardizedStandardized surgicalsurgical techniquetechnique
a)a) LeafletLeaflet pathologypathology ((prolapseprolapse) : ) :
1) Adequation of the free margin length:- Plication- Resection- Patch incorporation
2) Reinforcement of the free margin (PTFE)
b)b) RootRoot managmentmanagment ::
1) without root dilatation :- Subcommissural annuloplasty- STJ plasty (plication)
2) with root dilatation :- Remodeling- Reimplantation
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• Subcommissuralannuloplasty
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StandardizedStandardized surgicalsurgical techniquetechnique
a)a) LeafletLeaflet pathologypathology ((prolapseprolapse): ):
1) Adequation of the free margin length:- Plication- Resection- Patch incorporation
2) Reinforcement of the free margin (PTFE)
b)b) RootRoot managmentmanagment ::
1) without root dilatation :- Subcommissural annuloplasty- STJ plasty (plication)
2) with root dilatation :- Remodeling- Reimplantation
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Remodeling
Reimplantation
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SURGICAL TECHNIQUES (1)
• Radial plication: 13 % (9 pts)
• Triangular/raphe resection: 77 % (52 pts)• Patch incorporation : 13 % (9 pts)• Cusp extension 3 % (2 pts)
• Free margin reinforcement: 75 % (51 pts)• Subcommissural annuloplasty: 69% (47 pts)• STJ plasty 32 % (22 pts)• Root remodeling: 19 % (13 pts)• Root reimplantation: 29 % (20 pts)• Associated procedure: 28% (19
pts)
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SURGICAL TECHNIQUES (2)
• 2d run for AR > I or eccentric jet 5 pts
• Mean AoCCT 71 mn (36-155)
• Mean CPB 91 mn (66-194)
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HOSPITAL EVENTS (1)
• No mortality
• Morbidity :- 3 AR > II (4%) at days 7, 8 and 11 => REDO- 5 Bleeding- 1 BAV conduction 2/1 => Pace maker- 1 AMI => conservative treatment
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3 Early redo for AR > II
j7 : Median raphe suture disruption ⇒ re- repaired
J11 : Tricuspid autograft suture disruption ⇒re-repaired
j8 : Commissural disruption ⇒ Ross procedure
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HOSPITAL EVENTS (2)
• Mean hospital stay 9 d (5-21)
• Discharge echography:No AR 48 pts (70%)AR grade I (central) 19 pts (30%)
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LATE RESULTS (1)
Mean clinical Follow-up: 40 months (8-115)Mortality: 3 pts (not cardiac
related)Redo: 2 pts (3%): 1 AR and
1AS
One reoperation at month 23 : AR 3/4 , tric. patch perforation => ROSS procedure
One reoperation at month 98 : Ao Valve stenosis(calcifications) => RVAo
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LATE RESULTS (2)
• Echographic FU (median 26 months): 62 pts
- No AR progression 58 pts (94%)
- 4 patients with AR grade I → II (6%)
- mean peak gradient : 10±6 mmHg
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Survival proportions
0 10 20 30 40 50 60 70 80 90 1000
102030405060708090
100Survival
Months
%
SubjectSubject atat riskrisk: 67: 67 4040 2020 88 33
5y = 98 ± 3%
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Freedom from IAO> 2
0 10 20 30 40 50 60 70 80 90 10080
90
100Freedom from IAO >
Months
%
SubjectSubject atat riskrisk: 67: 67 3636 1515 66 33
5y = 97 ± 3%
Freedom from AR > 2
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SubjectSubject atat riskrisk:: 6767 3636 15 615 6 33
Freedom from Valvereoperation
0 10 20 30 40 50 60 70 80 9060
70
80
90
100Reoperations
Months
%
5y = 97 ± 3%
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Freedom from NYHA>2,Endocarditis,
Thromboembolism
0 10 20 30 40 50 60 70 80 90 10095.0
97.5
100.0
Months
%
SubjectSubject atat riskrisk: 67: 67 4040 2020 88 33
5y = 100%
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CONCLUSIONS • The absence of early post discharge reoperation
or recurrence of AR shows the stability of the repair achieved by our standardised surgicaltechnique
• The stabilisation and/or the replacement of the aortic root contributes in our opinion to the durability of the repair
• Leaflet management gives excellent mid termresults. Longer follow up is necessary for long termdurability
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MERCI