Valve Sparing Aortic Root Replacement

Valve Sparing Aortic
Root Replacement
Prof. Gebrine El Khoury, MD
Dr. Stefano Mastrobuoni, MD MPH
Dr. Michael O´Keefe, FRACS
Dr. Laurent De Kerchove, MD
DEPARTMENT OF CARDIOVASCULAR AND THORACIC SURGERY
ST. LUC HOSPITAL - BRUSSELS, BELGIUM
1
Repair-Oriented Classification of
Aortic Insufficiency
STJ – Sino-tubular Junction; SCA – Sub-Commissural Annuloplasty
JTCVS 2009;137:286-94
Reimplantation Technique:
step by step
Echocardiography assessment
Initial incision and inspection
Root Preparation
Graft Sizing
Proximal suture line
Handling of the Prosthesis
Distal suture line
Leaflet coaptation assessment
Coronary implantation
Valve Sparing Aortic Root Replacement
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Echocardiographic Assessment
Type Ib - AI
Tricuspid valve
Bicuspid valve
Type Ib + Type II- AI
Initial incision
 Open distal aorta and dissect proximally
 Avoid distally displaced right coronary and
LC-RC Commissure with dilated pathology
Valve Sparing Aortic Root Replacement
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Initial inspection
 2/3 commisural sutures
 Special consideration in Bicuspid Valve
Tricuspid
Bicuspid
Valve Sparing Aortic Root Replacement
Dilated VAJ and translucent aortic
6
wall tissue in BAV
Initial inspection
 Decision to make VSR in BAV without dilatation of the
root, depending on the quality of the aortic wall tissue
and dilatation of the VAJ
 Freedom from valve-reoperation increased with VSR
compared to Sub-Commissural Annuloplasty in case of
VAJ dilatation
100
VSR
p=0.0006
%
80
60
6 years
SCA
40
20
Group 1
64±15%
Group 2
95±5%
0
0
12
24
36
48
60
72
84
96
8
6
2
Months
No. at risk
Group 1
53
Group 2
53
42
33
27
21
18
39
29
23
20
15
14
10
9
De Kerchove L. Valve sparing root replacment with the reimplantation technique to increase the durability of bicuspid aortic
valve repair. JTCVS 2011:142:1430-1438.
Navarra E. Effect of annulus dimension and annuloplasty on aortic valve repair. EJCTS 2013
Base of Cusp Insertion
Conjoint Cusp
Bicuspid
Type 0
Pseudocommissure
Bicuspid
Type 1
Tricuspid
External Dissection
Start from Non
coronary Cusp
Follow to the Right and then to
Left coronary Cusps
Bicupid valve
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Valve Sparing Aortic Root Replacement
Root Preparation
Inside view of external limitation of the dissection
NC
LC
RC
Muscular septum
Valve Sparing Aortic Root Replacement
NC
Membranous septum
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External dissection
N/L
R/N
L/R
External Root Base
Basal Ring
Membranous septum
Muscular septum
Sizing of Valsalva graft
 Expose the non-left coronary commissure,
 Locate the « nadir » and the « tip »,
 Mesure the height of the commissure (NC/L),
=> Prosthesis size
Valve Sparing Aortic Root Replacement
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Proximal suture line:
VAJ annuloplasty
Tricupsid - Left and Non Coronary
Cusp
Tricupsid - RVOT
Place sutures in the horizontal pane
Bicupsid
Valve Sparing Aortic Root Replacement
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Graft trimming
to fit external root asymmetry
R/N
L/R
. .
. . . . . .
Muscular septum
N/L
. .
. .
. . . .
Membranous septum
Graft trimming
to fit external root asymmetry
Graft trimming
to fit external root asymmetry
NC/LC
commissure
LC/RC
RC/NC
commissure
commissure
Height of
external
limitation
Consequently this is somewhere in-between the the David and Yacoub
operations
El-Khoury
Valve sparing re-implantation
Yacoub
David
Remodeling
Re-Implantation
Proximal Suture Line
Effect on VAJ
Impact of proximal suture line
on VAJ remodelling
Tricuspid
Bicuspid Type 0
Bicuspid Type 1
Asymmetrical selective compression
Commissural suspension
 Re-suspend the commisures
 Bicuspid at 180 degree
 Tricuspid at 120 degrees
 Under tension of the commisural
sutures
 Leave these three points until
the distal anastomosis to the
remaining aorta
Valve Sparing Aortic Root Replacement
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Distal suture line
 Radial traction on the commissural sutures
 Allows easier exposure of the line of
reimplantation
Inadequate tension
 Small and regular steps
 Going from outside to inside and coming
back
Correct tension
Leaflet coaptation assessment
 Check the valve again and treat if
needed:
 Pre-op or post-sparing prolapse
management
 Leaflet free-edge plication
 Free margin resuspension
 Leaflet resection
Valve Sparing Aortic Root Replacement
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Leaflet coaptation assessment
 Important to recheck for prolapse and final
valve assessment as root geometry has changed
since reimplantation
Valve Sparing Aortic Root Replacement
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Coronary Buttons – Pearls:
 Place sutures at the origin of the left
coronary base
 Avoids kinking of the left main
 Use of a pericardial strip for re-
inforcement
 Particularly important in the
aortopathy
Left
Valve Sparing Aortic Root Replacement
Right
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The final Result: check for bleeding
 Final video of plegia down pressurized root
Valve Sparing Aortic Root Replacement
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The final Result:
check the post-CPB TEE ECHO
Conclusions…
Valve Sparing Aortic Root Replacement
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Conclusions - Pearls:
 Valsalva graft sizing
 Trimming of the proximal graft to accommodate
for muscular and membranous septum
 Pressurised cardioplegia delivery into the neo-
root to check for AI and bleeding
 Gross valve regurgitation assessment
Valve Sparing Aortic Root Replacement
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Conclusions - Pitfalls:
 Inadequate external dissection of the aortic root
(esp muscular septum)
 Lack/Failure of tension across the commissures
during all suture lines
 Over correction of leaflet prolapse with free
edge plication will create restriction (change
type II →type III)
Valve Sparing Aortic Root Replacement
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The End
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