The Aortic Valve and The Aortic Valve and The Aortic Root in The - - PowerPoint PPT Presentation

Optimal Optimal Surgical Surgical Technique Technique

The Aortic Valve and The Aortic Valve and The Aortic Root in The Aortic Root in Type A Aortic Dissections Type A Aortic Dissections

Type A Type A aortic aortic dissection dissection Objectives Objectives of

• f surgical

surgical repair repair

• Replace

Replace the the segment segment of

• f ascending

ascending aorta aorta where where the the intimal intimal tear tear occured

• ccured
• Treat

Treat aortic aortic regurgitation regurgitation

• Eliminate

Eliminate any any antegrade antegrade flow flow in in the the false false lumen lumen

• Keep

Keep the the patient patient ALIVE ALIVE

?

Type A Type A aortic aortic dissection dissection Surgical Surgical Technique Technique

• Emergency

Emergency surgery surgery

• «

« Open Open » » distal distal anastomosis anastomosis

• Avoid

Avoid aortic aortic Xclamp Xclamp

• Inspect

Inspect the the Transverse Transverse Ao Ao Arch Arch (30% (30% intimal intimal tear tear) )

• Antegrade

Antegrade flow flow

• AORTIC ROOT & VALVE ?

AORTIC ROOT & VALVE ?

….. Canulation of the Axillary Artery

Type A dissection Type A dissection Disease Disease of

• f the

the aortic aortic valve valve

• «

« de de novo novo » » aortic aortic regurgitation regurgitation due to due to detachment detachment of

• f one
• ne or more commissures
• r more commissures

and and prolapse prolapse of

• f the

the valve valve

• Preexisting

Preexisting disease disease of

• f the

the aortic aortic valve valve and and/or /or root root prior prior to to the the dissection dissection

How How was was the the aortic aortic valve valve PRIOR TO PRIOR TO dissection ? dissection ?

• Past

Past cardiac cardiac history history

• Prior

Prior echo echo studies studies

• Preoperative

Preoperative echo echo

• Operative

Operative findings findings

Intimal tear Intimal flap False lumen True lumen Aortic regurgitation

Status Status of

• f Aortic

Aortic VALVE & VALVE & ROOT ROOT PRIOR PRIOR to Dissection to Dissection

• Aortic

Aortic Valve Valve

• Normal

Normal

• Bicuspid

Bicuspid

• Calcified

Calcified

• Aortic

Aortic Regurgitation Regurgitation

• Aortic

Aortic Root Root

• Normal

Normal

• Dilated

Dilated

Bicuspid aortic Valve Normal aortic Root Cusp

Commissure

DILATED Aortic Root

Aortic Regurgitation

commissures

Normal Aortic Valve

False lumen Intimal flap

The commissure is detached and the cusp prolapse in the LV

Aortic Regurgitation In Aortic Dissection

Surgical Surgical Techniques Techniques Aortic Aortic Root Root & & Aortic Aortic Valve Valve

• Replace

Replace the the ascending ascending aorta aorta (GRAFT) (GRAFT)

• Nothing

Nothing on

• n the

the valve valve and and root root

• Resuspend

Resuspend the the valve valve

• Replace

Replace the the valve valve

• Replace

Replace the the valve valve and and root root ( (Bental Bental) )

• Replace

Replace the the root root (valve (valve sparing sparing) )

Surgical Surgical Techniques Techniques Aortic Aortic Root Root & & Aortic Aortic Valve Valve

• Replace

Replace the the ascending ascending aorta aorta

• Nothing

Nothing on

• n the

the valve valve and and root root

• Resuspend

Resuspend the the valve valve

• Replace

Replace the the valve valve

• Replace

Replace the the valve valve and and root root ( (Bentall Bentall) )

• Replace

Replace the the root root (valve (valve sparing sparing) )

Reconstruction of the distal aortic segment

(Obliterate the false lumen) (Resection of the segment that carries the intimal tear)

Replacement of the ascending aorta (supra coronary)

Nothing on the valve and the root

Surgical Surgical Techniques Techniques Aortic Aortic Root Root & & Aortic Aortic Valve Valve

• Replace

Replace the the ascending ascending aorta aorta

• Nothing

Nothing on

• n the

the valve valve and and root root

• Resuspend

Resuspend the the valve valve and and reconstruct reconstruct the the sinus sinus

• Replace

Replace the the valve valve

• Replace

Replace the the valve valve and and root root ( (Bentall Bentall) )

• Replace

Replace the the root root (valve (valve sparing sparing) )

Dissection of the Aortic Root

Non-coronary sinus

False lumen The intimal flap The commissure Is detached

Dissection of the Aortic Root Non-coronary sinus

False lumen Intimal flap

Detached commissure Commissure reattached

Reconstruction of the aortic root

Le faux chenal Resuspension of the commissures Occlusion of the false lumen

Reconstruction of the aortic root

Surgical Surgical Techniques Techniques Aortic Aortic Root Root & & Aortic Aortic Valve Valve

• Replace

Replace the the ascending ascending aorta aorta

• Nothing

Nothing on

• n the

the valve valve and and root root

• Resuspend

Resuspend the the valve valve

• Replace

Replace the the valve valve

• Replace

Replace the the valve valve and and root root ( (Bental Bental) )

• Replace

Replace the the root root (valve (valve sparing sparing) )

Aortic valve replaced Normal aortic valve

Surgical Surgical Techniques Techniques Aortic Aortic Root Root & & Aortic Aortic Valve Valve

• Replace

Replace the the ascending ascending aorta aorta

• Nothing

Nothing on

• n the

the valve valve and and root root

• Resuspend

Resuspend the the valve valve

• Replace

Replace the the valve valve

• Replace

Replace the the valve valve and and root root ( (Bental Bental) )

• Replace

Replace the the root root (valve (valve sparing sparing) )

Root Replacement (Bental)

Root replacement Ascending Aorta & Aortic Valve

Ascending Aorta

Surgical Surgical Techniques Techniques Aortic Aortic Root Root & & Aortic Aortic Valve Valve

• Replace

Replace the the ascending ascending aorta aorta

• Nothing

Nothing on

• n the

the valve valve and and root root

• Resuspend

Resuspend the the valve valve

• Replace

Replace the the valve valve

• Replace

Replace the the valve valve and and root root ( (Bental Bental) )

• Replace

Replace the the root root (valve (valve sparing sparing) )

1

2

3

Valve sparing operation remodelling (Yacoub) 1 3 2

Valve Valve sparing sparing operation

• peration

reimplantation reimplantation (David) (David)

?

Surgery Surgery for Type A for Type A dissections dissections

Operative Operative Mortality Mortality 10 10 – – 26 % 26 %

Sabik et al. J Thorac Cardiovasc Surg 2002

Long Long-

• term

term effectiveness effectiveness

Long Long-

• term

term study study

(Cleveland (Cleveland Clinic Clinic) )

• n = 208 patients

n = 208 patients

• 1978

1978-

• 1995

1995

• Operative

Operative mortality mortality

• Long

Long-

• term

term survival survival

• Impact

Impact of

• f different

different surgical surgical techniques techniques

Sabik et al. J Thorac Cardiovasc Surg 2002

Actuarial Survival

Sabik et al. J Thorac Cardiovasc Surg 2002

Actuarial Survival Actuarial Survival Bental Bental vs vs Resuspension Resuspension vs vs AVR AVR

Sabik et al. J Thorac Cardiovasc Surg 2002 Resuspension + graft (n=135) AVR + graft (n=26) Composite graft (n = 47)

Freedom from Freedom from Reoperations Reoperations Composite graft Composite graft vs vs Resuspension Resuspension

Sabik et al. JTCS 2002

Casselman et al Ann Thorac Surg 2000

Durability Durability of

• f the

the native native aortic aortic valve valve after after resuspension resuspension

Durability Durability of

• f the

the native native aortic aortic valve valve after after resuspension resuspension

• n = 246 patients

n = 246 patients (1976 (1976-

• 1999)

1999)

• Operative

Operative mortality mortality

• Long

Long-

• term

term survival survival

• Impact

Impact of

• f different

different surgical surgical techniques techniques

• Fate

Fate of

• f the

the root root & valve & valve

Casselman et al Ann Thorac Surg 2000

Actuarial Survival

Casselman et al Ann Thorac Surg 2000

Actuarial Freedom from Reoperation

Casselman et al Ann Thorac Surg 2000

2 2 >50 >50 1 1 46 46-

• 50

50 7 7 41 41-

• 45

45 9 9 36 36-

• 40

40 37 37 < 35 < 35 N N pts pts Diametre Diametre (mm) (mm)

Echocardiographic follow-up of the aortic root after conservative surgery for Type A dissections

Casselman et al Ann Thorac Surg 2000

Aortic Aortic Valve Valve Preservation Preservation

Long Long-

• term

term results results

• n = 200 patients

n = 200 patients

• Operative

Operative mortality mortality

• Long

Long-

• term

term survival survival

• Impact

Impact of

• f different

different surgical surgical techniques techniques

Von Segesser et al. J Thorac Cardiovasc Surg 1996

Actuarial Actuarial Survival Survival Bental Bental vs vs Graft Graft & & Resuspension Resuspension

Bental Graft + resuspension

Von Segesser et al. J Thorac Cardiovasc Surg 1996

Freedom Freedom from from Reoperation Reoperation

Bental Bental vs vs Graft Graft & & Resuspension Resuspension

Von Segesser et al. J Thorac Cardiovasc Surg 1996

Analysis Analysis of

• f the

the Results Results of

• f

the the « « integrated integrated approach approach » »

• n = 163 patients

n = 163 patients

• 1994

1994-

• 2002

2002

• Operative

Operative mortality mortality

• Long

Long-

• term

term survival survival

• Impact

Impact of

• f different

different surgical surgical techniques techniques

When When to replace to replace the the Aortic Aortic Valve ? Valve ?

• Conclusion

Conclusion

• Marfan

Marfan

• Dilation

Dilation of

• f the

the Valsalva Valsalva sinuses sinuses

• Bicuspid

Bicuspid or

• r

calcified calcified

Patients & Patients & Methods Methods

1986 - 2003. 162 patients Group A (n=89, 54.9%) had interposition

graft replacement of the ascending aorta with resuspension, repair or separate replacement of the aortic valve

Group B (n=73, 45.1%) underwent

composite graft replacement of the aortic root and ascending aorta.

Patients & Patients & Methods Methods

1990 - 2003 257 pts. were divided into 3 subgroups

by surgical treatment:

• 145 patients operated with SCR of

the ascending aorta,

• 64 patients were treated with a

composite graft (comp),

• 48 patients the native aortic valve

was reimplanted into a Dacron tube replacing the ascending aorta (AVS)

Early Early mortality mortality

Type A Dissection Type A Dissection : : Disease of the aortic root Disease of the aortic root

Root Abnormal Root Abnormal Valve Abnormal Valve Abnormal Root Abnormal Root Abnormal Valve Normal Valve Normal Root Normal Root Normal Valve Abnormal Valve Abnormal Root Normal Root Normal Valve Normal Valve Normal

Type A Dissection Type A Dissection : : Disease of the aortic root Disease of the aortic root

Graft replacement of Graft replacement of the ascending aorta the ascending aorta Valve Valve resuspension resuspension Root Normal Root Normal Valve Normal Valve Normal

Type A Dissection Type A Dissection : : Disease of the aortic root Disease of the aortic root

Root Abnormal Root Abnormal Valve Abnormal Valve Abnormal Root Abnormal Root Abnormal Valve Normal Valve Normal Root Normal Root Normal Valve Abnormal Valve Abnormal Root Normal Root Normal Valve Normal Valve Normal

Type A Dissection Type A Dissection : : Disease of the aortic root Disease of the aortic root

Graft replacement of Graft replacement of the ascending aorta the ascending aorta Root Normal Root Normal Valve Abnormal Valve Abnormal Valve replacement Valve replacement

Type A Dissection Type A Dissection : : Disease of the aortic root Disease of the aortic root

Root Abnormal Root Abnormal Valve Abnormal Valve Abnormal Root Abnormal Root Abnormal Valve Normal Valve Normal Root Normal Root Normal Valve Abnormal Valve Abnormal Root Normal Root Normal Valve Normal Valve Normal

Type A Dissection Type A Dissection : : Disease of the aortic root Disease of the aortic root

Root Abnormal Root Abnormal Valve Abnormal Valve Abnormal

Root replacement Composite Graft Bental

Type A Dissection Type A Dissection : : Disease of the aortic root Disease of the aortic root

Root Abnormal Root Abnormal Valve Abnormal Valve Abnormal Root Abnormal Root Abnormal Valve Normal Valve Normal Root Normal Root Normal Valve Abnormal Valve Abnormal Root Normal Root Normal Valve Normal Valve Normal

Type A Dissection Type A Dissection : : Disease of the aortic root Disease of the aortic root

Valve sparing Valve sparing Root Abnormal Root Abnormal Valve Normal Valve Normal Total Replacement Total Replacement

• f the aorta
• f the aorta

Conclusion Conclusion

• The

The surgical surgical technique technique should should be be adapted adapted to to operative

• perative findings

findings

• Graft

Graft replacement replacement of

• f the

the ascending ascending aorta aorta and and valve valve resuspension resuspension offer

• ffer

excellent excellent results results

• More extensive

More extensive operations

• perations are

are associated associated to a to a higher higher operative

• perative

mortality

• mortality. BUT

. BUT … ….. ..

Type A Dissection Type A Dissection

• 1993

1993 – – 2005 2005

• N = 44

N = 44

• M/F 32/12

M/F 32/12

• Age = 61 (39

Age = 61 (39-

• 84)

84)

• Marfan

Marfan = 0 = 0

Surgical Technique Surgical Technique

• Arterial canulation

Arterial canulation

• < June 1994 femoral artery

< June 1994 femoral artery 8/44 8/44

• 1994

1994 – – 2002 2002 axillary axillary artery artery 36/44 36/44

• Open distal

Open distal anastomosis anastomosis 42/44 42/44

• Hemiarch

Hemiarch 39/42 39/42

• Total arch

Total arch 3/42 3/42

• Aortic root

Aortic root

• Ao

Ao valve valve resuspension resuspension 41/44 41/44

• Ao

Ao valve replacement valve replacement 2/44 2/44

• Composite graft

Composite graft Bental Bental 1/44 1/44

Cerebral Protection Cerebral Protection

• DHCA

DHCA t<16 t<16 ˚

˚ C

C 41/42 41/42

• Retrograde perfusion (1994)

Retrograde perfusion (1994) 8/42 8/42

• Antegrade

Antegrade perfusion perfusion 34/42 34/42

• Circulatory arrest time

Circulatory arrest time

• < 30 minutes (19

< 30 minutes (19-

• 30)

30) 30/42 30/42

• 30

30 – – 45 minutes 45 minutes 7/42 7/42

• > 45 minutes

> 45 minutes 4/42 4/42

• > 60 minutes

> 60 minutes 1/42 1/42

Results Results

• 30

30-

• day mortality

day mortality 4/44 (9%) 4/44 (9%)

• Causes of death

Causes of death

• Neurological

Neurological 1/4 1/4

• Respiratory

Respiratory 1/4 1/4

• MOF

MOF 2/4 2/4

• Morbidity

Morbidity

• Neurological

Neurological 4 (3 transient) 4 (3 transient)

• Renal

Renal 1 (dialysis 1mo) 1 (dialysis 1mo)

• Respiratory

Respiratory 6 6

Echo follow Echo follow-

• up (1

up (1-

• 5years)

5years)

• Aortic valve

Aortic valve

• AR = 0

AR = 0 21/29 21/29

• AR = 1+

AR = 1+ 7/29 7/29

• AR = 2+

AR = 2+ 1/29 1/29

• Diameter of the aortic root

Diameter of the aortic root

• < 40 mm

< 40 mm 27/29 27/29

• 43,45 mm

43,45 mm 2/29 2/29

Conclusion Conclusion

• Open

Open distal distal anstomosis anstomosis

• Adapted

Adapted surgical surgical technique to technique to

• perative
• perative findings

findings at at the the level level of

• f the

the aortic aortic root root

• Graft

Graft replacement replacement of

• f the

the ascending ascending aorta aorta and and valve valve resuspension resuspension offer

• ffer

excellent excellent results results