Aortic valve repair

Prof. Antonio ScafuriCardiac Surgery

PTV – Rome1 ottobre 2012

• Valve preserving root replacement surgery, using the reimplantation or remodeling techniques, is increasingly being used to treat aortic root disease

• Although this techniques for aortic valve repair for isolated aortic insufficiency (AI) are applied heterogeneously and infrequently

• A major limitation to the more generalized application of aortic valve repair techniques is the absence of a common framework for valve assessment which can help to guide the approach to valve repair

The mobility of the valve cusps can be viewed as a ratio between the free margin length and the length of the base of cusp implantation:

Goal of AV repair:Restore a normal surface of coaptation by restoring normal

geometry to the leaflets, while preserving normal mobility of the AV cusps.

Cusp Mobility: Free Margin LengthLength of Cusp Insertion

Boodhwani et al. J Thorac Cardiovasc Surg 2009;137:286-94

Aortic valve sparing

• Remodelling technique

• Reimplantation technique

David et al. J Thorac Cardiovasc Surg 2006;132:347-354

David et al. J Thorac Cardiovasc Surg 2006;132:347-354

David et al. J Thorac Cardiovasc Surg 2010;140:14-19

David et al. J Thorac Cardiovasc Surg 2010;140:14-19

Subcommissural anuloplasty

• It is important to stabilize the functional aortic annulus, which consists of the ventriculo-aortic junction and the sinotubular junction.

• Pledgeted 2-0 braided suturesare used

• This maneuver helps to stabilize the ventriculo-aortic junction, reduces the width of the interleaflet triangles and increases the coaptation surface of the valve leaflets.

•Subcommissural annuloplasty is typically performed at mid-commissural height, except at the non-coronary/right coronary commissure where it should be performed

higher in order to avoid the membranous septum and conduction tissue.

Boodhwani et al. “Repair oriented calssification of aortic insufficiency..”

Triangular resection Patch extension

Minakata et al. J Thorac Cardiovasc Surg 2004;127: 645-653

Fattouch et al. Interact Cardiovasc and Thorac Surg 2012;15: 644-650

De Kerchove et al. European J of Cardiothorac Surg 2008;34: 785-791

De Kerchove et al. European J of Cardiothorac Surg 2008;34: 785-791

Boodhwani et al. J Thorac Cardiovasc Surg 2009;137:286-94

Boodhwani et al. J Thorac Cardiovasc Surg 2009;137:286-94

Aicher et al. Eur J Cardiothor Surg 2010;37: 127-132

Esperienza centro

Aicher et al. Eur J Cardiothor Surg 2010;37: 127-132

Aicher et al. Eur J Cardiothor Surg 2010;37: 127-132

Boodhwani et al. J Thorac Cardiovasc Surg 2010;140:276-94

BAV

Sintesi studi

• Buoni i risultati globali• IA secondaria ha migliori risultati(radicalità)• Specie nelle valvole tricuspidi• IA isolata (prolasso una cuspide) meno bene

(forse meglio nelle bicuspidi)• Risultati migliori con procedure associate• Tecniche associate meno riproducibili

Le Polain de Waroux et al. JACC: Cardiovasc Imag 2009;8:931-9

Le Polain de Waroux et al. JACC: Cardiovasc Imag 2009;8:931-9

• Riproducibili Tecniche• Ruolo Ecocardiografia • Filosofia dell’atteggiamento chirurgico (in

Proverbi …..cerca la Giusta via e prendila…)

CONCLUSIONI