The aorto-ventricular junction
in aortic repair
Emmanuel Lansac,
Isabelle Di Centa
Cardiac Surgery
Institut Mutualiste Montsouris,
Paris, France
Dystrophic roots: a matter of diameters
Root aneurysm
Aicher
2007
Normal
aortic
root
22.3
(20.5-24.5)
STJ Ø
(mm)
26.7
(24.7-29.5)
Lansac
2010
84
144
100 521
193
Annulus Ø (mm)
26±
±2
26.3 (25.1-27.6)
26.5±6.3
25.1±3
Dilated>25
mm
27.6±2.5
STJ Ø (mm)
40±
±6
46.1 (40-51.2)
Dilated>35
mm
51.2±9.1
45.5±6.1
47.8±11
Supra-coronary aneurysms
David
2007
1132
Annulus Ø
(mm)
Pacini
2009
N
Echo studies
1987-2011
N
Settepani
2009
Morimoto
2009
Asano
2012
N
103
276
29
144
Annulus Ø (mm)
NA
24.4
± Dilated
21.6±1.6
27.3±2.4
STJ Ø (mm)
39 ±9
35
35.1±3.7
Dilated=35
mm
30.7±3.4
Isolated AI
Sato
2003
Izumoto
2009
N
11
19
Annulus Ø (mm)
26.1± 2.1
STJ Ø (mm)
39.2 ± 5.1
168
Schäfers
2009
Lansac
2011
111
27
25.1±
2.4(25.1-28)
26.5
Dilated>25
mm 27
42±35.6
±14Dilated
(28.5-42) 28.5
28±1.4
32.7±2
The surgical correction of aortic insufficiency
by circumclusion
Taylor WJ, et al. JTCVS 1958;35:192-231
First subvalvular aortic annuloplasty
Beating Heart Right thoracotomy
11 patients, rheumatic disease (8/11)
Subcommissural plication stitches
(Cabrol stitches)
Plicating U stitches at the base
of the interleaflet triangles
Plicating U stitches at the
commissures
= partial subvalvular annuloplasty
= partial supravalvular annuloplasty
Plication of the interleaflet triangles impairing valve dynamics
especially for bicuspid valves
significant gradient
minimal reduction in aortic annular base diameter
Risk minor
factor amounts
for bicuspid
aorticannular
valve repair
Useful when
of aortic
base failure
reduction are
needed or to protect a commissural repair
De Kerchove EJCTS 2012
Aicher Circulation 2011
Aortic annuloplasty devices
Experimental
Calves
roots
In vivo
(18 sheep)
In vivo
(5 sheep)
In vivo
(4 calves)
Duran 1993
Internal ring
Porcine
roots
Reimold 1994
External ring
Gogbashian 2007
External band
Porcine
roots
6 months
in vivo (1 calf)
Rankin 2011
Internal ring
Scharfschwerdt 2011
Internal or external ring
Techniques for aortic annuloplasty
Isolated AI
Carpentier
1983
Hahm
2006
Frater
1986
Lansac
2007
Haydar
1997
Schäfers
2009
Need for standardization
Izumoto
2002
Fattouch
2011
Anderson R H MMCTS 2007;2007:mmcts.2006.002527
The aortic root has been opened from behind and spread apart, so that the full width of the
cylinder can be seen.
Anderson R H MMCTS 2007;2007:mmcts.2006.002527
-1.7 mm
-2.84 mm
2,18 mm
1.68 mm
-2.94 mm
Com NC-L
Nadir NC
Nadir L
2.16 mm
+ 1.7 mm
Com L-R
3.35 mm
+ 1.6 mm
2.69 mm
+ 3.0 mm
3.24 mm
Nadir R
Com R-NC
An Expansible aortic ring
Reduces aortic annular base diameter in diastole (-15%)
Increases cusp coaptation height (+130%)
10% systolic expansibility mimics natural annulus dynamics
Protects the repair and reduces cusps’stress
Annuloplasty for root aneurysms
Remodeling
of the aortic root
Reimplantation of
the aortic valve
Yacoub 1983
David 1992
+ Treatment of STJ +
dilation
Supravalvular
annuloplasty
+
Sinuses of
Valsalva
±
+
Aortic Root
expansibility
(interleaflet
triangles)
-
-
Treatment of
aortic annular
base dilation
+
Sub and supravalvular
annuloplasty
First series of Remodeling
Burkhart JHVD 2003 21.2%Risk
reoperation
at 22.5repair,
months
factor : Cusp
aortic annulus >25 mm
Lansac EJTCVS 2006 32.7% intra-operative
conversion,
13.6%
at 17 M
Risk
Sub
factor
valvular
: aortic
external
annulus
aortic
≥reoperation
25ring
mm
Hancke JTCVS 2009
Risk factor:
Marfan, cusp
anulus>26 mm
AI increased
with repair,
time inaortic
both groups
David JTCVS 2010
Anulus dilation if Ø>27 mm men, Ø >25 mm women
Post Remodeling of the aortic root
Kunihara JTCVS 2011
Post STJ remodeling
Asano EJCTS 2012
Physiological and standardized approach
to aortic valve repair
extrait racine plus foncé
+
Remodeling
Reimplantation
=
Remodeling +
subvalvular annuloplasty
Standardization based on aortic annulus Ø
Aortic annular base Ø (Hegar dilators, mm)
25-27
28-30
31-33
34-39
≥ 40
Valsalva graft® Ø (mm)
26
28
30
32
34
Extra aortic ring® Ø (mm)
25
27
29
31
33
Subvalvular ring = down size from one size
Tube graft = ring Ø + 1 mm
6 subvalvular « U »
stitches
Aligment of cusp free
edges prior Remodeling
Suture of the
Remodeling
3
6
4
1
Cusp resuspension
after the Remodeling
(effective height ≥9 mm)
2
Subvalvular ring
implantation
Repair for isolated aortic insufficiency
6 subvalvular « U »
stitches
Aligment of cusp free
Cusp resuspension
edges
(effective height ≥9 mm)
Placement of the open subvalvular ring
below the coronaries
Final aspect
Film faugere court?
Goals for aortic valve repair
1. Treatment of the dilated diameters
- aortic annular base = aortic annuloplasty
- STJ
= STJ remodelling
2. Preserve root dynamics
- neosinuses of Valsalva
- preserve expansibility through the interleaflet
triangles
3. Restore cusp effective height
Phenotypes of the ascending aorta
Aortic root
aneurysm
Valsalva ≥45 mm
Supra-coronary
aneurysm
Valsalva<40 mm
STJ>45 mm
Isolated AI
Valsalva<40 mm
STJ<40 mm
Standardized and physiological approach to aortic valve repair
Root reconstruction
Supra-coronary
graft
+ sub-valvular
annuloplasty
Remodeling
+ sub-valvular
annuloplasty
Subvalvular
annuloplasty
(annulus > 25 mm)
Cusp repair
+
Resuspension of cusp effective height
Subvalvular aortic annuloplasty