Aortic Annuluplasty System
Aortic Valve Anuluplasty SystemDesigned by Khalil Fattouch, MD, PhD.Aortic valve What we learn from the mitral valve? Surgeons are not concerned about the valve, but with the Aortic Functional Unit Aortic anulus Cusps Valsalva sinus Commissures Sinotubular Junction Ascending aorta
Relationship between severals Aortic Root Components are important for normal valve function AA > STJ (10-15%)
Coaptation high = 0.5-0.8 cmHigh of opened leaflet = 70% of sinus
Tipo Ia- STJ Dilation
Functional Classification of AR Tipo I:Normal leaflet motion
Tipo II:Excessive leaflets motionTipo III:Restrictive leaflets motion Ia STJ dilation Ib dilation of valsalva sinuses Ic FAA dilation Id Perforation
Calcification Cusp fusionLesson from mitral valve repairAnuluplasty is a fundamental step in mitral valve repair:
re-shape the anulus stabilize the repair improve long term results
Aortic AnulusWhat is the true valve anulus ?7What we measure with 2D echo when we are supposted to measure the anulus, is what is market in the slide.
Aortic Anulus8However, if we defined annulus as a ring of fibrous tissue that sustains the cusps, what we measure with echo has not an anatomic equivalent. Actually in the aorta the annulus is not ring-shaped but crown-shaped structure. The highest parts are called commisures, the inner parts nadir.
Interleaflet trianglesBasal circumferenceSinutubular ridgecommissuresFunctional Aortic AnulusFAA = (Anatomical anulus + STJ)9The cusps are attached in a scalloped fashion. The support of the aortic leaflets seem to be as a suspension bridge and is very effective. Because of that, there are three triangular extension of left ventricular outflow tract, whithin the aortic root which reach the level of the sinotubular junction. Although these interleaflet triangles are unequivocally part of the aortic root, they are exposed to the hemodynamics of LV rather than of the aorta.
10Once again the aortic root motion downwards the LV cavity can be easily appreciate with the 3D echocardiography. Ring for aortic valve repairmust:
1. re-shape the functional aortic anulus
2. Stabilize the continuity between the aortic valve annulus and the STJ.The second point of viewInterleaflets Triangles Are essentials for normal leaflets opening and normal distribuition of stress
AnnulusMechanism of Opening:sequence of leaflets opening
Stellate orificeSmall triangleTriangleCircular orifice
From stellate orifice to small triangleIncrease in ventricular pressure through the interleaflet triangle causes an increase of diameter at the commissures (STJ) before the valve opens
Answer to the first paradox: the valve opens before the presence of forward flowThe second objective?
The ring for aortic valve repair must,
Leave the commissures and the interleaflets triangle free to move during the cardiac cicle, that is essentialfor a normal leaflets motion and stress distribuition
Today, what we do in aortic valve repair?Subcommissures plasty
Our idea, to re-shape the functional aortic anulus and preserve aortic leaflets motionRe-shape the STJRe-shape the anatomical anulus
From inside LV outflow tractFrom outside the aorta
abSuture TechniqueLeave free the interleaflets triangles
Re-shape the sinotubular junctionApplied outside to the aorta at the level of the STJ and sutured to the aorta with the same suture line when we close the aortotomy using 4-0 prolene.
The 3 crown were sutured at the level of commissures and fixed to the internal ring using the same ticron U-stitch used previously.
The D shape of the annulus avoid blood turbolence under the aortic valve Flexible zoneFree from suture
Suture TechniqueObjectiveRe-shape and Stabilize the functional aortic annulus
Undersize the anatomical aortic annulus from inside ofLV outflow tract (improve leaflets coaptation).
Leave the interleaflets triangles and commissures free to move that is mandatory for a normal leaflets stress distribuition and motion (opening).
An external application of a ring may lead to cusps prolapse.
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