Repair for Aortic Regurgitation: is it...

Repair for Aortic Regurgitation:is it durable ?

Gébrine El Khoury

Cliniques Universitaires St-Luc, IREC, UCL, Brussels, Belgium

AATS 95th Annual Meeting

25-29 April, Seattle

Aorrtic valve repairthe basics

• -role of the functional aortic annulus:FAAdilation

• -role of the free margin of the leaflets:FMelongation

Yacoub David

• First « basic »:

Despite of normal leaflets, root aneurysms (FAA

Dilation) may induce aortic regurgitation, and

the restoration or recreation of normal root

(FAA) corrects the regurgitation.

Concept:

LESION DYSFUNCTION

TREAT THE LESION, CORRECT THE DYSFUNCTION


Leaflet prolapse:excess length of free margin, shortening (plication) correct prolapse and AR

Leaflet prolapse: excess length of free margin

shortening (plication) of the free margin correct prolapse and AR

-Second « basic »:


• -third « basic »

-Close relationship betweec FAA and FM

leaflet coaptation and MOTION

-close relationship between FAA and AR

FAA dilation AR


Understanding Valve Dysfunction

Echocardiographic

Assessement

Classification

Surgical

Assessement

STJ – Sino-tubular Junction; SCA – Sub-Commissural Annuloplasty

JTCVS 2009;137:286-94Dysfunction etiology lesion repair

Classification of Dysfunctions

Functional classification of aortic regurgitationMechanism of AV dysfunction

Type 1 AR : FAA dilatation

Type 1a

(STJ)

Type 1b

(STJ+VAJ)

Type 1c

(VAJ)

Cusp perforation (Type 1d)

AV repair for AI: Mechanisms of AI

Cusp prolapse (Type 2)


Restricted cusp motion (Type 3)


Fundamental Principlesof Valve Repair

- Preserve or restore normal motion

- Create a large surface of coaptation

- Remodel and stabilize the annulusClose functional

relationship(functional unit)

Leaflets

Determinants of durabilty:

• Quality &quantity of tissue, patient selection

• Appropriate surgical technique - Excellent immediate result of repair

Leaflet coaptation,motion FAA stabilisationLong term durability

Valve repair and durability

A. Quality & quantity of tissue, patient selection

B. Appropriate surgical technique

AV repair for AI: Determinant of durability

- Moncuspid

- Bicuspid

- Quadricuspid

- Connective tissue disorders (Marfan, Loeys-Dietz, Ehler-Danlos, Familial Aneurysmal disease, …)

Congenital

AV repair for AI: Etiology

- Degenerative cusp

- Degenerative aorticaneurysm

(Atherosclerosis)

- Traumatic

- Infectious

- Acute aortic dissection

Acquired


- Ross repair

- Re-repair

Redo







AV repair for AI: Actual requirementOptimal coaptation + Stabilisation

Pethig K. ATS 2002le Polain de Waroux JB. JACC Card. Im. 2009

Bierbach BO. EJCTS 2010Aicher D. Circ. 2011

De Kerchove L. JTCVS 2011

• Effective height (eH) ≥ 9 mm

• Coaptation length ≥ 4 mm

• Circumferential annuloplasty

VAJ >26 mm

• No residual AR

A. Quality & quantity of tissue, patient selection

B. Appropriate surgical technique

AV repair for AI: Determinant of durability

El Khoury G. Cur. Op. Card. 2005

AV repair for AI: Mecanisms of AI

Supracoronary Ascending Aortic Aneurysms (Type 1A)

Freedom from AV Reoperation

0 24 48 72 960

20

40

60

80

100

No. at risk 55 41 28 10 3

Months

Fre

ed

om

fro

m A

V R

eo

pera

tio

n

97%

95%

95%

Freedom from Reop

AV repair for AI: Root dilatation (Type 1b) - VSRR

T. David JTCVS 2014

78%

93%

91%

Freedom from AR ≥2+

No predictors of recurrent AR

• Toronto: 1988 – 2010, 371 pts, 9% BAV, 50% cusp repair

• Homburg: 1995 – 2009, 430 pts, 30% BAV, 73% cusp repair

T. Kunihara JTCVS 2012



Freedom from AV reop.

• Brussels: 1996 – 2014, 275 pts, 43% BAV, 70% cusp repair

S. Mastrobuoni STSA 61st meeting 2014

100%92%


AV repair for AI: Root dilatation (Type 1b)

in Marfan syndrome

T. David, JTCVS 2009

Freedom from AR >2+Freedom from AV reoperation

• Toronto: 1988 – 2006, 103 pts, mean age 37 y

vssr+cusp repair

AV Repair for AI: VSRR +/- Cusp repair

H.J. Schäfers Ann Thor Surg 2002 L. de Kerchove Circulation 2009

AV Repair for AI: Results Prolapse repair (Type 2)

M. Boodhwani, JTCVS 2011

93%

93%

87%

Tricuspidisation and

3 cusps extension

Sharma V. JTCVS 2014

Risk factors of reop: Severe preop AR, > mild AR at discharge

79% 72%75% 58%

• Mayo: 1986 – 2011, 331 pts, 40% BAV, 100% cusp repair

AV repair for AI: Isolated AICusp prolapse/restriction/perforation (Type 2,3, 1d)

AV repair for AI: Predictor of recurrent AICusp restriction (Type 3)

M. Boodhwani, JTCVS 2009

Freedom from AR >2+Freedom from AV reoperation

(Prolapse)(Restriction)

(Prolapse)(Restriction)

• Cusp Height to define cusp restrictionTAV < 16 mmBAV < 19 mm Schafers H.J. JTCVS 2013

AV repair for AI: Predictor of recurrent AICusp extension/restoration with Patch

Aicher D. Circ. 2011 Boodhwani M. JTCVS 2010

AV Leaflet Repair: ResultsLeaflet repair with patch

Mozala Nezhad Z. EJCTS 2014






AV repair for AI: Predictor of recurrent AICoaptation length and height

le Polain JB. JACC Card. Im. 2009

Tips < annulus

Tips > annulusResidual ARCoapt < 4 mm

Residual AR, Coapt >4 mm

Tips > annulus, No AR

AV repair for AI: Predictor of recurrent AICoaptation length and height

Aicher D. Circ. 2011






Aicher D. Circ. 2011

AV repair for AI: Predictor of recurrent AILarge ventriculo-aortic junction


BAV repair Remodeling

No circumferential annuloplasty

de Kerchove EJCTS 2015


Navarra E. EJCTS 2013

Non-circumferential Subcommis. Annuloplasty (Cabrol stitch)

TAV repairBAV repair


B

0 2 4 6 8 100

20

40

60

80

100

VSR VAJ 28mm

VSR VAJ 28mm

p=0.38

Years

%

Pts at riskVAJ 27 88 52 35 18 8 2VAJ >27 56 44 33 18 9 6

A

0 2 4 6 8 100

20

40

60

80

100

SCA VAJ 28mm

SCA VAJ 28mm

p=0.0001

Years

%

Pts at riskVAJ 27 117 92 61 44 23 7VAJ >27 18 13 8 1

De Kerchove L. EJCTS 2015

Circumferential annuloplasty in VS Reimplantion


De Kerchove L. JTCVS 2011

0 12 24 36 48 60 72 84 960

20

40

60

80

100

6 years

64±15%

95±5%Group 2

p=0.0006

No. at risk

Group 1 53 42 33 27 21 18 15 10 8

Group 2 53 39 29 23 20 14 9 6 2

Group 1

Months

%

SCA

VSR

Matched comparison VSR vs SCA

Freedom from AR>1+

AV Leaflet Repair: Conclusions

• The mechanism of AR are actually well understood and the use of a classification of AR help to plan AV repair.

• Surgeon dispose of a wide armamentarium of repair techniques adapted to the variety of valvular lesions.

• Durability of leaflet repair depend on the quality and quantity of tissues; long term results are excellent for prolapse repair and acceptable for repair of restrictive lesion.

• Next to leaflet tissues quality, optimal valve coaptation and annuloplasty are other determinants of repair durability.

• Still, longer follow-up is necessary to investigate 2°decade after aortic valve repair.

• Is it durable ? Yes

Respect determinants of durabilty:

• Quality & quantity of tissue, patient selection– Type 3 (calcif., short geom. height), patch repair

• Appropriate surgical techniques– Optimal cusp coaptation, motion

– FAA stabilisation

AV repair for AI: Conclusions

Thank you

AV repair for AI: Patient demographic

• Mean age of patient with isolated AI:

- 57 y Roberts WC. Circulation 2006

- 53 ± 14 y Sharma V. JTCVS 2014

- 59 y (TAV) vs 40 y (BAV) De Meester C. AHA 2012

• Mean age of patient with aortic aneurism ± AI

- 47 ± 15 y T. David JTCVS 2014

- 57 ± 15 y T. Kunihara JTCVS 2012

- 44 ± 11 y (BAV) F.A. Kari ICVTS 2014

Johnston D.R. Ann Thor Surg 2015

Bioprosthesis durability in pts < 60 y

→ 20 – 30 % of SVD @ 15 y

Bourguignon T. ATS 2015


Johnston DR. ATS 2015 Bourguignon T. Ann Thor Surg 2015

50 y

55 y

60 y

> 25 % reop. @15 y for patient < 50 y

AV repair for AI: Hospital mortality in elective surgery

• 0.6% V. Sharma, H. Schaff JTCVS 2014

• 0.8% J. Price, G. Elkhoury ATS 2013

• 0.8% D. Aicher, H-J Schafers EJCTS 2010

• 1% T. David JTCVS 2014

AV Repair: Long term Survival

V. Sharma, H. Schaff JTCVS 2014

J. Price ATS 2013 T. David JTCVS 2014

90%

81%

73%

81%

90%80%

77%

AV repair for AI: Patients

Mean age of patient with severe AI: 50 ± 17 year

- Tricuspid 59 ± 14 year- Bicuspid 40 ± 13 year De Meester C. AHA 2012

Johnston DR. ATS 2015 Bourguignon T. ATS 2015


Johnston DR. ATS 2015


Bourguignon T. Ann Thor Surg 2015

Johnston D.R. Ann Thor Surg 2015


→ 20 – 30 % reoperation for SVD @ 15 y

• Homburg: 1995 – 2009, 430 pts, 30% BAV, 73% cusp repair



AV repair for AI: Root dilatation (Type 1b)

AV Leaflet Repair: ResultsLong term outcomes (1995 – 2010 : 475 pts, 68% leaflet repair)

J. Price ATS 2013

84%

86%

AV Repair: Freedom from Reoperation & AI

Authors Period Cohort TechniqueFF AV Reop

FF recurrent AR >2+

H. SchaffJTCVS 2014

1986- 2011 331 Cusp 100%Sparing 0%

10 y 80% 10 y 75%

T. KuniharaJTCVS 2012

1995-2007 640 Cusp 80%Sparing 50%

10 y 88% 10 y 80%

J. Price ATS 2013

1995-2010 475 Cusp 68%Sparing 50%

10 y 86% 10 y 85%

T. David JTCVS 2014

1988- 2010 371 Cusp 50%Sparing 100%

10 y 97%

18 y 95%

10 y 93%

18 y 78%

Root pathology > Cusp pathology

AV repair for AI: TAV versus BAV

BAV

• 84% (7 y) Casselman JTCVS 1999

• 81% (10 y) Aicher EJCTS 2010

• 81% (10 y) Price ATS 2013

TAV

• 94% (12 y) David JTCVS 2010

• 93% (10 y) Aicher EJCTS 2010

• 89% (10 y) Price ATS 2013

Freedom from reoperation

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