Aortic root surgery Decision making

1. Aortic root surgeryDecision making KriengchaiPrasongsukarn, MD, MSc

2. Case 1 Case ผู้หญิงไทย อายุ 25 ปี underlying Marfan’s syndrome, married, want to pregnant CXR:Dilatation of ascending aorta Echo/TEE: severe AR ,EF 70%,no RWMA, dilated aortic root at sinus part of aorta 5.05 cm, LVOT 2.4 cm, Ascending aortic dilate 5.6 cm indiameter

3. Operation ? Tissue Valve/ Homograft Replacement Mechanical Valve Replacement Composite valve graft (Bentall operation) Ross Operation Aortic valve sparing

4. Case 2 Case ผู้หญิงไทย อายุ 22 ปี DX severe AS (อายุ 19 ปี ) s/p AV commissurotomyหลังทำ3 months มีเหนื่อย ประมาณ 1-2 เดือน หลังจากคลอดบุตรคนแรกผู้ป่วยเหนื่อยมากขึ้น ตรวจพบว่ามี severe AR, ผู้ป่วยมาปรึกษาแพทย์ว่าถ้าหลังจากการผ่าตัดแล้ว ผู้ป่วยยังอยากที่จะมีบุตรต่อ

5. Case 2 Echo: EF 62%, Severe AR (regurgitation flow 1114 ms., PHT 323 ms.), tricuspid and torn leaflet, no calcification

6. Operation ? Tissue Valve/ Homograft Replacement Mechanical Valve Replacement Composite valve graft (Bentall operation) Ross Operation Aortic valve sparing

7. Case 3 Case ผู้ชายไทยอายุ 21 ปี severe AR ผู้ป่วยมาปรึกษาแพทย์ เรื่องการผ่าตัดว่า หลังการผ่าตัดผู้ป่วยไม่ขอ on anticoagulant Echo: EF 61%, severe AR (PHT 128-150 ms.), LVEDD 65 mm, LV enlargement, Aortic annulus 2.75 cm., Pulmonic valve 2.61-2.69 cm., Aortic Valve are trileaflets, retracted and rolling.

8. Operation ? Tissue Valve/ Homograft Replacement Mechanical Valve Replacement Composite valve graft (Bentall operation) Ross Operation Aortic valve sparing

9. Case 4 Case ผู้ชายไทย อายุ 24 ปี มาด้วย ไข้ เหนื่อย Dx:BE with severe AR, รักษาได้ ATB ครบ 6 wk คลำได้ก้อนที่บริเวณก้นด้านซ้าย(AVM at left buttock) Echo:Severe AR, EF 60%, Aortic root 28.8 mm, sinotubular junction 28 mm, aortic root 24.8 mm, tricuspid AV, vegetation size 24x9.9 mm attached to left cuspand down to septum, pulmonic valve 24. mm

10. Operation ? Tissue Valve/ Homograft Replacement Mechanical Valve Replacement Composite valve graft (Bentall operation) Ross Operation Aortic valve sparing

11. Case 5 Case ผู้ชายไทย อายุ 40 ปี มาด้วยเหนื่อยมากขึ้นขณะสอนหนังสือ CXR: Dilatation of of ascending aorta CTA: Aortic aneurysm at ascending aorta size 6.2 cm in diameter. Echo: moderate AR, EF 48%, ascending aortic aneurysm 6 cm in diameter, no evidence of ascending aortic dissection, LVOT 4.2 cm, STJ 5.2 cm, tubular diameter 4.2 cm, AV 3 leaflets, no MR/MS

12. Operation ? Tissue Valve/ Homograft Replacement Mechanical Valve Replacement Composite valve graft (Bentall operation) Ross Operation Aortic valve sparing

13. Case 6 female59 years old, chest pain, FC III CXR: Dilatation of of ascending aorta Echo: moderate AR, EF 39%, ascending aortic aneurysm 5 cm in diameter, no evidence of ascending aortic dissection, sinus valsava 6 cm, AV 3 leaflets rolling and retracted of leaflets, mild MR

14. Operation ? Tissue Valve/ Homograft Replacement Mechanical Valve Replacement Composite valve graft (Bentall operation) Ross Operation Aortic valve sparing

15. Tissue valve

16. AVR - Hancock II Bioprosthesis from TGH • 670 patients • Mean age: 65+/-12 years (range 18 to 87) • Sex: male - 75% female - 25% • ECG: sinus - 92% AF - 8% • Previous AVR - 10%

17. AVR - Hancock II Bioprosthesis • NYHA functional class I - 3% II - 23% III - 43% IV - 31% • AV lesion: AS - 46% AI - 25% Mixed - 29%

18. AVR - Hancock II Bioprosthesis • Infective endocarditis: Active - 24 pts Healed - 11 pts • Coronary artery disease: 297 pts (44%) • Ascending aortic aneurysm: 73 pts (11%) • Left ventricular EF: >40% - 428 pts (64%) <40% - 143 pts (21%) N.A. - 99 pts (15%)

19. AVR - Hancock II Bioprosthesis Operative Data: • Valve size: #21 = 48 pts (7%) #23 = 198 pts (30%) #25 = 208 pts (31%) #27 = 174 pts (26%) #29 = 42 pts (6%) • Aortic annulus enlargement: 125 pts (19%) #21=24 pts; #23=53 pts; #25=58 pts

20. AVR - Hancock II Bioprosthesis • Operative mortality - 32 pts (5%) • Operative morbidity: Bleeding/tamponade - 33 (5%) Myocardial infarction - 9 (1.3%) Stroke/TIA - 22 (3.2%) Sternal infection - 4 (0.6%) Early endocarditis - 2 (0.3%)

21. AVR - Hancock II Bioprosthesis • Follow-up: 86+/-45 mo. (range 0 - 200) 99% complete • Deaths: Total - 237 (35.3%) Operative - 32 (13.5%) Valve-related - 28 (12%) Cardiac-related - 81 (34%) Other causes - 96 (40.5%)

22. Hancock II: AVRSurvival

23. Hancock II: AVRFree From Structural Valve Dysfunction

24. Hancock II: AVRFree From Structural Valve Dysfunction

25. Hancock II: AVRFree From Reoperation

26. AVR: Hancock II BioprosthesisSummary of Events 5yr 10yr 15yr Freedom from: Death 79% 61% 47% Thromboembolism 95% 87% 83% Endocarditis 98% 97% 96% Tissue failure 100% 97% 81% Reoperation 98% 94% 77%

27. AVR: CE Perimount CE Perimount No. Patients 310 Mean Age +/-S.D. 65+/-12 NYHA class IV 33% Coronary artery disease 41% Banbury et al - Ann Thorac Surg – 2001;72:753

28. AVR with CE PerimountFreedom from Failure 15 yr = 77% Banbury et al - Ann Thorac Surg – 2001;72:753

29. The Journal of Thoracic and Cardiovascular Surgery October 2005 Carpentier-Edwards supra-annular aortic porcine bioprosthesis: Clinical performance over 20 years W.R.Eric Jamieson and colleagues

30. AV Bioprostheses: Freedom from Tissue Failure Pt’s age 15 years Hancock II David et al 65±11 81% Rizolli et al 67±8 89% CE Perimount Banbury et al 65±12 77% Neville et al 68±11 94% (12yr) Frater et al 65±12 85% (14yr) SJM Biocor 69 76% CE porcine 69 75%

31. AV BioprosthesesFreedom from Failure • Jamieson’s discussion “There is no apparent difference in failure rates of second generation porcine valves and CE Perimount…”

32. Homograft

33. AVR with Aortic Valve Homograft • Versatile: Sub-coronary implantation Aortic root inclusion Aortic root replacement • Excellent flow characteristics, particularly when used as an aortic root replacement device • Drawbacks: Limited availability Limited durability

34. Durability of Aortic Valve Homograft

35. AVR with Aortic Valve HomograftFreedom from Reoperation 10 year = 87% 15 year = 76% Pts’ mean age = 47 yrs Pts at risk 546 450 148 12 O’Brien et al. J Heart Valve Dis 2001;10:334

36. AVR with Aortic Valve Homograft Freedom from reoperation  Freedom from failure

37. AVR with Aortic Valve HomograftFreedom from Reoperation & Failure Freedom from ReoperationFailure 10-year 81%65% 20-year 62%18% Lund et al. J Thorac Cardiovasc Surg 1999;117:77

38. AVR with Aortic Valve Homograft Drawbacks: • Limited availability • Limited durability • Complicated reoperation: high op mortality • Better than xenografts?

39. Stentless valve

40. AVR with Medtronic FreestyleFreedom from Reoperation 10 yr = 92% Pts at risk 488 346 305 218 118 30 Bach et al. – Ann Thorac Surg 2005;80:480

41. AVR with Medtronic FreestyleFreedom from Moderate/Severe AI 10-year: Sub-coronary = 87% Root replaced = 98% Pts’ mean age = 72 years Bach et al. – Ann Thorac Surg 2005;80:480

42. AV Homograft vs. Medtronic Freestyle Medina et al. Three-dimensional in vivo characterization of calcification in native valves and in Freestyle versus homograft aortic valves J Thorac Cardiovasc Surg 2005;130:41 Quantitative evaluation of calcium deposits in the aortic valve by electron beam tomography data fusion technique: Freestyle had lower amounts of calcium than aortic valve homograft 2 years after implantation

44. Choice of Valve in Active Infective Endocarditis of the Aortic Valve Conventional wisdom Aortic valve homograft is the best valve to treat patients with active infective endocarditis, particularly if an abscess is present

45. Aortic Root Replacement with Aortic Valve Homograft • 1989-2003 • 213 patients • Mean age: 51 years • Indication for surgery: 73 – Native AV endocarditis 52 – Prosthetic AV endocarditis • All 213 patients had aortic root replacement • Operative mortality 16/213 (7.5%)  58% Kaya et al. – Ann Thorac Surg 2005;79:1491

46. Aortic Root Replacement with Aortic Valve Homograft Freedom from adverse events (survivors only): 5-year 10-year Freedom from death 87% 71% Freedom from reoperation 94% 76% Kaya et al. – Ann Thorac Surg 2005;79:1491

47. Aortic Root Replacement with Aortic Valve Homograft • Reasons for reoperation: 20/194 12 – Homograft failure 3 – False aneurysm 3 – Endocarditis in the homograft 3 – Other reasons • Reoperation mortality: 25% • Endocarditis in the homograft: 4 cases Kaya et al. – Ann Thorac Surg 2005;79:1491

48. Aortic Valve Homograft for Aortic Root Abscess • 1987-2003: 161 patients • 78 sub-coronary implantation • 83 aortic root replacement • 83 aorto-ventricular discontinuity • 81 prosthetic valve endocarditis • Operative mortality: 9.3% urgent; 14.3% emergent • 11 early reoperations for dehiscence/infection • 73% free from reoperation at 10 years Yankah et al - Eur J Cardio-Thorac Surg 2005;28:69

49. Aortic Valve Surgery for Active Infective Endocarditis • Infection limited to valve cusps = simple AVR • Infection extended into paravalvular tissues = radical resection of all seemingly infected tissues and reconstruction with appropriate patches

50. Surgery for Active Infective EndocarditisExperience at Toronto General Hospital • 418 patients • Mean age: 52±16 years • Sex: 65% male • Native valve: 287 (68%) • Prosthetic valve: 131 (32%) • Paravalvular abscess: 150 (36%)