Aortic valve sparing operation

Rating : Rate It:
 
There is no comments now for this Slide.
Post a comment
    Post Comment on Twitter
Comments:  



  Notes
 
 
Slide 1 : Aortic Valve Sparing Operation …. Systematic Review Presented by Dr: Ibrahim Emam Fellow Of Egyptian Board Of Cardiac Surgery
Slide 2 : Surgical anatomy of aortic root The aortic root has four components ? Aortic annulus ? Aortic cusps ? Aortic sinuses ? Sinotubular junction In addition, the triangles beneath the commissures of the aortic valve (1)
Slide 3 : Aortic annulus the aortic annulus is 15 to 20% larger than the diameter of the sinotubular junction of young persons Unites the aortic cusps and aortic sinuses to the left ventricle Is attached to the interventricular septum in approximately 45% of its circumference and to fibrous structures (anterior leaflet of the mitral valve and membranous septum) in the remaining 55% The aortic annulus has a scalloped shape the bundle of His immediately lay below the membranous septum, which travels through the right fibrous trigone The aortic cusps are attached to the aortic annulus in a scalloped fashion (2)
Slide 4 : Aortic cusps The aortic cusps have a semilunar shape the length of the base is approximately 1.5 times longer than the length of the free margin There are three cusps and three aortic sinuses: left, right and noncoronary The highest point where two cusps meet is called the commissure and it is located immediately below the sinotubular junction The two triangles beneath the commissures of the noncoronary cusp are fibrous whereas the triangular space beneath the commissure between the left and right cusps is muscular (1)
Slide 5 : Aortic sinuses There are three aortic sinuses: left, right and noncoronary. The left coronary artery arises from the left aortic sinus and the right coronary artery arises from the right aortic sinus the right coronary artery orifice is higher than the left the aortic sinuses play no role in valve competence but they are believed to minimizing mechanical stress on the aortic cusps during the cardiac cycle(1)
Slide 6 : Sinotubular junction The sinotubular junction is the end of the aortic root changes in the sinotubular junction can affect the function of the aortic cusps. (2)
Slide 7 : Aortic Valve Pathology In Adults Aortic stenosis (dystrophic calcification, senile calcification, or degenerative calcification) normally occur late in life Aging and high levels of lipoprotein and active inflammation, were found to be correlated with aortic valve sclerosis Degenerative calcification of the aortic valve is the most common cause of aortic stenosis in elderly patients in North America(3)
Slide 8 : Aortic Valve Pathology In Adults Bicuspid aortic valve Occurs in 1 to 2% of the population Calcified bicuspid aortic valve is the second most common cause of aortic stenosis in elderly patients Bicuspid aortic valve can also cause AI, particularly in young patients in whom mild to moderate dilation of the aortic root is present (4)
Slide 9 : Aortic Valve Pathology In Adults (Bicuspid aortic valve) Most of the patients have an anterior cusp attached to the interventricular septum and a posterior cusp attached to the fibrous components of the LVOT The anterior cusp often contains a raphe at approximately where the commissure between the right and left cusps would be The raphe extends from the mid-portion of the cusp to the aortic annulus, and its insertion in the aortic root is at a lower level than the other two commissures(4)
Slide 10 : The two cusps are of different sizes and the larger one often contains a raphe Most patients with bicuspid aortic valve have three aortic sinuses Bicuspid aortic valves with two aortic sinuses and no raphe are uncommon RCA is nondominant in most patients with bicuspid aortic valve.(4) Aortic Valve Pathology In Adults (Bicuspid aortic valve)
Slide 11 : Aortic Valve Pathology In Adults Unicusp aortic valve Is another congenital anomaly of the aortic valve It often contains only one commissure and causes aortic stenosis Associated with premature degenerative changes of the media of the aortic root and ascending aorta. They increase the risk of aneurysms and type A aortic dissection (5)
Slide 12 : Aortic Valve Pathology In Adults Quadricusp aortic valve Is a rare anomaly may cause aortic insufficiency Three of the four cusps are usually of similar size and the other is hypoplastic(6)
Slide 13 : Aortic Valve Pathology In Adults VSD Can cause AI, but not common in adult The aortic valve lose his support due to VSD The right aortic cusp is often elongated and may prolapse and cause aortic insufficiency.
Slide 14 : Aortic Valve Pathology In Adults Aortic dissections involving the ascending aorta can cause aortic insufficiency because of detachment of one or more commissures with consequent prolapse of the cusps. Connective tissue disorders (e.g., ankylosing spondylitis, osteogenesis imperfecta, rheumatoid arthritis, Reiter syndrome, and lupus) can cause aortic insufficiency. The anorexigenic drugs phentermine and fenfluramine can also cause aortic insufficiency. Dilation of the aortic root is the most common cause of aortic insufficiency in North America, aortic insufficiency developed because of dilation of the sinotubular junction, and is common in patients with Marfan syndrome(6)
Slide 15 :  Selection Of Patients For Aortic Valve Repair Mildly or moderately stenotic aortic valves in whom the primary indication for operation is myocardial revascularization are amenable to manual débridement to increase cusp mobility The calcific deposits should be limited to small segments of one or two cusps and in proximity to the aortic annulus. Ultrasound decalcification should be avoided because it causes scarring with retraction of the cusps Most candidates for aortic valve repair have aortic insufficiency the aortic cusps are the most important determinant of aortic valve repair If the cusps are thin, mobile, and have smooth free margins, the feasibility of aortic valve repair is very high Patients with aortic root aneurysm who have normal or minimally stretched aortic cusps (7)
Slide 16 : Selection Of patients For Aortic Valve Repair Larger aortic root aneurysms (e.g. >60 mm) often have overstretched, thinned out aortic cusps with stress fenestrations along the commissural areas and are not suitable for repair. Patients with ascending aortic aneurysm and aortic insufficiency often have dilated sinotubular junction and normal or minimally altered aortic cusps. The aortic insufficiency is central and caused by outward displacement of the commissures of the aortic valve, aortic valve repair is usually feasible in these patients. Aortic insufficiency caused by prolapse of a single cusp(8)
Slide 17 : Technique Of Aortic Valve Repair
Slide 18 : Cusp Perforation Causes Iatrogenic A sequel of healed endocarditis Resection of a papillary fibroelastoma Surgical repair A simple patch of fresh or glutaraldehyde fixed autologous pericardium is adequate to correct the problem. If fresh autologous pericardium is used, the patch should be larger than the defect because it retracts during healing continuous 7-0 polypropylene used to suture the patch around the defect on the aortic side of the cusp.(8,9)
Slide 19 : Cusp Extension Causes rheumatic congenital disease Surgical repair Glutaraldehyde-fixed bovine or autologous pericardium has been used for this purpose.(9)
Slide 20 : Cusp Prolapse Causes due to elongation of the free margin Surgical repair It is not always simple base of the aortic cusp is 1.5 times longer than the length of its free margin( requires some experience) Pulling upward on the commissures without causing distortion of the scallop-shaped annulus, observing the level of the nodule Arantius is a useful maneuver to assess cusp prolapse, the level of the central portion of the free margin should lie closer to the level of the commissures corrected by plication along the nodule of Arantius ,the degree of shortening is determined by examining the other cusps (8,9)
Slide 21 : Cusp With Stress Fenestration Causes Dilation of the sinotubular junction increases the mechanical stress along the free margin of the cusp Surgical repair Corrected by weaving a double layer of 6-0 expanded polytetrafluoroethylene suture along the free margin of the cusp.(9)
Slide 22 : Bicuspid Aortic Valve Causes Congenital bicuspid aortic valve with prolapse of one cusp The most commonly performed aortic valve repair in adults The anterior cusp is usually the one that is elongated and prolapsed Surgical repair The raphe is excised the free margin plicated The lengths of the free margins of both cusps should be similar and should coapt at the same level the subcommissural triangles narrowed with sutures(10)
Slide 23 :
Slide 24 : Ascending Aortic Aneurysm with Aortic Insufficiency (AI) Dilation of the sinotubular junction displaces the commissures of the aortic valve outward These patients are often in the sixth, seventh, and eighth decade of their lives  Commissures of the noncoronary aortic cusp are more affected than the other two (11)
Slide 25 : Ascending Aortic Aneurysm with AI (operative management) If the other components of the aortic root are normal ?simple adjustment of the sinotubular junction restores valve competence This is accomplished by Transecting the ascending aorta 5 mm above the sinotubular junction and pulling the three commissures upward and close to each other until the cusps coapt The three commissures form an imaginary triangle The diameter of a circle that contains this imaginary triangle is the diameter of the graft that should be used to reconstruct the sinotubular.(11) 
Slide 26 : Ascending Aortic Aneurysm with AI (operative management) 4- The diameter of the graft and the space between commissures are determined by a transparent valve sizer 5- One or more cusps may be elongated and the free margin has to be shortened  6- Aortic valve competence can be tested at this time by injecting cardioplegia into the graft under pressure and observing the left ventricle for distention.(11)
Slide 27 : Ascending aortic aneurysm Aortic root aneurysm Dilation of STJ ?AI Dilation of STJ Dilation of aortic annulus
Slide 28 : Ascending Aortic Aneurysm with AI (operative management) If the noncoronary aortic sinus is dilated or altered by aortic dissection, a neo-sinus can be created by tailoring the graft with a tongue of tissue that is sutured directly to the aortic annulus The height of the neo-sinus of Dacron should be 3 or 4 mm more than the diameter of the graft, and the width should be 3 or 4 mm more than the estimated intercommissural distance.(11)
Slide 29 : Aortic Root Aneurysm The indication for surgery is more often due to the diameter of the root at the level of the aortic sinuses than due to the severity of AI, a large proportion of patients have none, trace, or mild aortic insufficiency at the time of surgery Access the degree of valve prolapse Assessing dilation of the aortic annulus by the transverse diameter of the aortic annulus has to be smaller than the average length of the free margins of the cusps the radius of the aortic annulus must be smaller than the average height of the cusps types of aortic valve–sparing operations for patients with aortic root aneurysm - remodeling of the aortic root - reimplantation of the aortic valve.(12)
Slide 30 : Aortic Root Aneurysm (remodeling of the aortic root) Surgical technique The ascending aorta is transected All three aortic sinuses are excised, leaving approximately 4 to 6 mm of arterial wall attached to the aortic annulus and around the coronary artery orifices The three commissures are gently pulled vertically and approximated until the cusps coapt The three commissures form a triangle and the diameter of the circle that contains that triangle is the diameter of the graft to be used the sizers of the Toronto SPV bioprosthesis are very useful to determine the diameter of the graft and also the distance between commissures because they may not be equidistant .(12)
Slide 31 : Aortic Root Aneurysm (remodeling of the aortic root) The spaces in between the commissures are marked in one of the ends of the graft, and the graft is tailored to create three neo-aortic sinuses The heights of these neo-sinuses should be approximately equal to the diameter of the graft The three commissures are suspended in the graft then sutured to the aortic annulus and remnants of the aortic wall with continuous 4-0 polypropylene sutures.(12)
Slide 32 : Aortic Root Aneurysm (remodeling of the aortic root) 5- The coronary arteries are reimplanted into their respective neo-sinuses 6- The aortic cusps are inspected , If one or more cusps is prolapsing, the free margin is shortened as described before 7- Aortic valve competence can be assessed by injecting cardioplegia under pressure into the reconstructed aortic root and observing the left ventricle for distention 8- The graft is then anastomosed to the distal ascending aorta or transverse aortic arch graft, depending on the extent of the aneurysm.(12)
Slide 33 : Aortic Root Aneurysm (remodeling of the aortic root) Remodeling of the aortic root may be inappropriate for patients with Marfan syndrome or annuloaortic ectasia because the annulus may continue to dilate and cause aortic insufficiency. An aortic annuloplasty along the fibrous component of the LVOT did not prevent late dilation of the aortic annulus in patients with Marfan syndrome. Thus, reimplantation of the aortic valve may be a better operative procedure for patients with annuloaortic ectas.(12)
Slide 34 : Reimplantation of the aortic valve Indication: this procedure can be performed in all patients with aortic root aneurysm, but it is particularly valuable in patients with annuloaortic ectasia and in those with acute type A aortic dissection. Principle: The aortic valve was reimplanted into a tubular Dacron graft and neo-aortic sinuses were created The presence of the aortic sinuses is important for normal cusp motion, and potentially, cusp durability There is now a commercially available graft with sinuses.(13)
Slide 35 : Reimplantation of the aortic valve Steps The three aortic sinuses are excised, and the coronary ostia Multiple horizontal mattress sutures of 2-0 or 3-0 polyester are passed from the inside to the outside of the LVOT, immediately below the nadir of the aortic annulus, through a single horizontal plane A tubular Dacron graft of diameter equal to double the average height of the cusps is selected three equidistant marks placed in one of its ends, A small triangular segment is cut off along the mark that corresponds to the subcommissural triangle of the left and right cusps The sutures previously placed in the LVOT are now passed through the graft .(13)
Slide 36 : Reimplantation of the aortic valve The sutures should be spaced symmetrically if the aortic annulus is not dilated If there is obvious dilation of the aortic annulus, the sutures should be closer together beneath the subcommissural triangles of the noncoronary cusp, because that is where dilation A special piece of equipment, called a Hegar's dilator, is placed in the left ventricular outflow tract, through the aortic valve. The size of the dilator is based on the patient's body size The sutures are then tied on the outside of the graft The graft is then cut to a length of approximately 5 cm and pulled gently the three commissures are also pulled vertically and temporarily secured to the graft with transfixing 4-0 polypropylene sutures the commissures and the cusps are inspected to make sure they are all correctly aligned the sutures are tied on the outside of the graft and used to secure the aortic annulus into the graft .(13)
Slide 37 : Reimplantation of the aortic valve The coronary arteries are reimplanted into their respective sinuses The coaptation of the aortic cusps is inspected and prolapse is corrected if necessary. It is important that the coaptation level is well above the aortic annulus Neo-aortic sinuses are created by plicating the graft at the level of the commissure Valve competence can be assessed by injecting cardioplegia into the graft and inspecting the ventricle for distention or by echocardiography. The mean graft size range from 26 to 34 m.(13)
Slide 38 :
Slide 39 :
Slide 40 : Results Of Aortic Valve Repiar
Slide 41 : Repair of Incompetent Bicuspid Aortic Valve The freedom from reoperation was 84% at 7 years. Aortic valve repair with those of aortic valve replacement with biologic valves The 5-year freedom from reoperation was 91 ± 5% for repair and 94 ± 6% for replacement (p = 0.2) the freedom from moderate or severe aortic insufficiency was 79 ± 8% for repair and 94 ± 6% for replacement (p = 0.024).(14)
Slide 42 : Ascending Aortic Aneurysm with AI Patients’ Survival Pts at risk 88 79 70 61 50 42 34 27 19 8 52±6% David TE et al.
Slide 43 : Freedom From Aortic Insufficiency Pts at risk 88 79 70 61 50 42 34 27 19 8 4+ = 99±0.5% >3+ = 90±3% Severe AI = 1 pt Moderate AI = 2 pts David TE et al.
Slide 44 : Freedom From Aortic Valve Replacement Pts at risk 88 79 70 61 50 42 34 27 19 8 95±2% Reoperations: 1 for endocarditis 1 for AI David TE et al.
Slide 45 : 76 46 13 9 26 24 16 0 Percent Free Years Postoperatively Patients at risk p=0.15 At 15 years Reimplantation = 94.7 ± 5% Remodeling = 66.5 ± 1.3% Freedom From Greater Than Mild AI Reimplantation vs. Remodeling David TE et al.
Slide 46 : References Kunzelman KS, Grande J, David TE, et al: Aortic root and valve relationships: impact on surgical repair. J Thorac Cardiovasc Surg 1994; 107:162 Silver MA, Roberts WC: Detailed anatomy of the normally functioning aortic valve in hearts of normal and increased weight. Am J Cardiol 1985; 55:454. Warren BA, Hong JL: Calcification of the aortic valve: its progression and grading. Pathology 1997; 29:360. Cecconi M, Manfrin M, Moraca A, et al: Aortic dimensions in patients with bicuspid aortic valve without significant valve dysfunction. Am J Cardiol 2005; 95:292 Edwards WD, Leaf DS, Edwards JE: Dissecting aortic aneurysm associated with congenital bicuspid aortic valve. Circulation 1978; 57:1022 David TE: Surgery of the aortic valve. Curr Probl Surg 1999; 36:421. McBride LR, Nauheim KD, Fiore AC, et al: Aortic valve decalcification. J Thorac Cardiovasc Surg 1990; 100:36. Duran CM, Gometza B, Shahid M, et al: Treated bovine and autologous pericardium for aortic valve reconstruction. Ann Thorac Surg 1998; 66(6 Suppl):S166.
Slide 47 : References 8- Duran CM, Gometza B, Shahid M, et al: Treated bovine and autologous pericardium for aortic valve reconstruction. Ann Thorac Surg 1998; 66(6 Suppl):S166. 9- Al Halees Z, Al Shahid M, Al Sanei A, et al: Up to 16 years follow-up of aortic valve reconstruction with pericardium: a stentless readily available cheap valve? Eur J Cardiothorac Surg 2005; 28:200. 10- Casselman FP, Gillinov AM, Akhrass R, et al: Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet. Eur J Cardiothorac Surg 1999; 15:302. 11- David TE, Feindel CM: An aortic valve-sparing operation for patients with aortic insufficiency and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992; 103:617. 12- David T, Feindel CM, Webb GD, et al: Long term results of aortic valve sparing operations for aortic root aneurysm. J Thorac Cardiovasc Surg 2006; 132:347. 13- Bethea BT, Fitton TP, Alejo DE, et al: Results of aortic valve-sparing operations: experience with remodeling and reimplantation procedures in 65 patients. Ann Thorac Surg 2004; 78:767. 14- Casselman FP, Gillinov AM, Akhrass R, et al: Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet. Eur J Cardiothorac Surg 1999; 15:302.
Slide 48 : Nothing impossible
Slide 49 : Thank you

 


Related  Most Viewed

More By User

Flag as inappropriate

Free Medical Powerpoint Templates
Add as Friend ibrahim7502010@gmail.com     1 Years ago.

Category: cardiac surgery
Tags:
Embed:
588 Views, 0 favourite
for education





Featured | Myworld | Browse | Patients | Popular | Latest | Tags | Conferences | Contact | Feedback | About Us | FAQ | RSS

Powerpoint Templates

Animated Powerpoint Templates | Business Powerpoint Templates | Education PPT |Mac PPT | Medical Powerpoint Templates |Powerpoint Maps | Technology PPT

copyright © www.SlideWorld.org