Breve presentazione in inglese sulla sostituzione della valvola aortica in OS (open surgery) e in TAVR (aortic valve replacement transcatheter). Short presentation in English on the aortic valve replacement in OS ( open surgery ) and TAVR ( transcatheter aortic valve replacement )

1. Luigi Farina
Facoltà di Medicina e Chirurgia
Università “Sapienza” - Polo Pontino
Anno Accademico 2013-2014 – Esame di Inglese III – Prof. L. Herdon
Aortic Valve Replacement

2. 1

3. 2
SUMMARY
 Historical Background ..............................................................................4
 Heart Anatomy and Physiology................................................................7
 Aortic Valve Anatomy............................................................................11
 Steps of AVR - Open Heart Surgey........................................................12
 TAVR - TRANSCATHETER AORTIC VALVE REPLACEMENT....14
 Preoperative management .................................................14
 Patient selection.................................................................14
 Preparation........................................................................14
 Operative techniques .........................................................14
 Imaging ..............................................................................14
 Surgical access ..................................................................16
 Balloon valvuloplasty ........................................................18
 Positioning.........................................................................19
 Deployment ........................................................................19
 Surgical closure .................................................................20
 Conclusion .........................................................................20
 FAQ.........................................................................................................22
 What causes a failure of the aortic valve?.........................22
 There are signs of a failure of the alarm aortic valve? .....22
 How do i know if i have to be at work aortic valve? .........23
 There are differences between implants and mechanical
organic?.............................................................................23
 How is the surgery performed? .........................................24
 Why i need surgery? ..........................................................24

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 Alternatives to surgery.......................................................25
 Results of treatment failure................................................25
 What 'the risk of surgery?..................................................25
 What will my condition after replacing aortic valve? .......26
 Article 1 – Surgical treatment of aortic valve endocarditis ....................27
 Article 2 – Aortic stiffness is an indicator of cognitive dysfunction ......28
 Article 3 – “Fast-implantable” aortic valve ............................................29
 Article 4 - Retrograde cardioplegia administration ................................30
 Article 5 – mid-term results for aortic roof replacement ........................31
 Article 6 – Percutaneous aortic valve replacement.................................32
 Bibliography ...........................................................................................33
 Sitography...............................................................................................33

5. 4
HISTORICAL BACKGROUND
In folio 115 of the Corpus of the anatomical Studies Leonardo Da Vinci
shows numerous drawings of the aortic valve and the structures attached to
it. This folio is one of the richest examples of precise and accurate method
of Da Vinci, but also the most difficult to clarify the anatomical pages of
Leonardo. The constant Leonardo's interest in the aortic valve is shown by
the frequent recurrence of drawings of the structure of the tricuspid aortic
valve, pointing to the fact that he was particularly attracted by its symmetry.
In addition, he wrote: "Non permettere a nessuno che non sia matematico
di legere mja principles" ("Do not let anyone who is not a mathematician
read my principles"). Already in the school of Pythagoras, the circle in the
plane and the sphere in space, were considered the perfect figures for their
symmetry and rotation. In fact, in the drawings of Leonardo, the tricuspid
aortic valve, in a circle appeared to be a perfect example of symmetry and
rotation.
The interest in Leonardo, as a mathematician, not only ended with the
geometric symmetry of the aortic valve, but it also expanded to fluid
dynamics. When each component was analyzed, Leonardo guessed its
function with a vivid imagination and tried to reconstruct the whole.
Analyzing the flow through the vessel and breasts had been able to
understand how the task of the aortic valve was done, in particular for what
concerns the opening and closing.
The concept of morphological and functional unit of the aortic valve is
introduced already Leonardo with a simple question: “…Perchè il buso
della arteria aorto è triangolare?..." (" ... Why is the aortic artery orifice
triangular? ... ").

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It was probably Erasistratus, in the third century BC, who first described
the three membranes at the level of the aortic and pulmonary orifices. The
graphical representation of a tricuspid aortic valve (but also lung) is one of
the first in the history of medicine, although Leonardo did not exclude the
possibility that the valves had 4 or 2 flaps.
And 'certainly hard to believe that Leonardo had ever seen a Quadricuspid
or bicuspid aortic valve, while it is more likely that it was a result of his
fertile imagination. The fact is that the incidence of bicuspid aortic valve is
about 0.52% in each of the 100 infants and 0.008% in the case of valve
Quadricuspid. Surely, Leonardo had little chance to find a bicuspid valve
and a valve Quadricuspid even less likely in his 30 anatomical dissections,
if we consider that Simmonds reports only 2 cases of valve Quadricuspid in
a total of 25666 autopsies. Leonardo clear and clearly differentiated three
different anatomical configurations, which seem rather a geometric
reasoning that a reproduction of a direct experience. Determined that: "...
per la qual cosa langolo più ottuso è più forte chellangolo retto del
quadra..." ("... for this reason, the obtuse angle is stronger than the right
angle of the square ..."). Indeed, in a tricuspid valve closed, in the center of
the aorta each flap forms an angle of 120° while in the configuration with
four flaps is 90°. He explained that the orifice of the valve with four square
edges, is larger than the triangular orifice inserted in the same circle;
accordingly, the valve
leaflets Quadricuspid are
weaker, because the
corners of the closure are
more remote from the
base of the triangle. In
this way, Leonardo in a
simple way, anticipated
the concept of increased
stress of the flaps in the presence of congenital diseases. This concept was
recognized much importance in the design and construction of biological
prostheses or in cases of conservative surgery of the aortic valve.

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Leonardo clearly understood that the durability of the valve was largely
dependent on
the fact that the
aortic valve
leaflets were
shares of the
aortic wall.
Observation of
his drawings
you understand that Da Vinci had also realized that the valve leaflets were
not connected in a circular manner but rather in the manner of the crown
(the fibrous skeleton) defining small triangular structures of the ventricle,
which have been recently re-evaluated.
Leonardo wrote that the aortic valve opens from the blood that "affect" and
close the blood that is "reflected". Also considered that the "impetus" of the
blood goes from the ventricle to the aorta and that this stretches and expands
the flaps upward. He also explained that the speed of the blood could depend
on the different diameters of the aorta: “...major velocita nella mjnor
larghezze dessa canna…”
("...the higher the speed
when the port is smaller,
less when it is larger ...").
For Da Vinci, the area of
coaptation was of vital
importance in
maintaining the cusps
closed, so that the blood
would not return back into the ventricle. I realized that was not the case in
the coaptation level of the free margin but at the level of the "belly" of the
flaps.
Thanks to the intuition and reasoning of Leonardo, the importance of the
area of coaptation in the efficiency and durability of the valve function are
underlined.
In conclusion, not only Leonardo understood the role of the flow of blood
through the sinuses of Valsalva, which represents the basis of the complex
mechanism of closure of the aortic valve, but also the lees a reference to the
importance of the stress at the level of the aortic valve leaflets, the
coaptation of the cusps and the concept of functional anatomy at the
microscopic level.

8. 7
HEART ANATOMY AND PHYSIOLOGY
The heart is an unequal organ, cable, consisting of involuntary striated
muscle tissue. Its main function is to set in motion the blood in the vessels;
for this is comparable to a pump, which, contracting, pushes the blood
towards the various tissues and organs. Has a shape that resembles an
upside-down pyramid. At birth, the heart weighs 20-21 grams and, in
adulthood, reaches 250 grams in women, and 300 grams in humans. The
heart lies in the chest, at the level of the anterior mediastinum, rests on the
diaphragm and is slightly shifted to the left. It is surrounded by the
pericardium, a sac serousfibrous, which has the task of protecting and
limiting distensibility. The heart wall is formed by three tunics
superimposed, from outside to inside are named:
 Epicardium: It is the outermost layer, in
direct contact with the serous pericardium. It
consists of a surface layer of mesothelial cells that
rests on the underlying layer of dense connective
tissue, rich in elastic fibers.
 Myocardium: It is the intermediate layer,
consisting of muscle fibers. The myocardial cells are
called cardiomyocytes. It depends both on the
contraction of the heart, both the thickness of the
heart wall. It is necessary that the myocardium is
properly perfused and innervated, respectively by a
vascular network and a nerve.
 Endocardium: It is the lining of the heart chambers
(atria and ventricles), consisting of endothelial cells
and elastic fibers. A separate it from the
myocardium, there is a thin layer of loose
connective tissue
The internal shape of the heart can be divided into two halves: a left and a
right part. Each part consists of two cavities, or chambers, distinct, called
the atria and ventricles, within which the blood flows. Atrium and ventricle
of each half are placed, respectively, one above the other. On the right side,
you have the right atrium and the right ventricle; on the left side, you have
the left atrium and the left ventricle. A clear separation of the atria and

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ventricles of the two halves, there are, respectively, an interventricular
septal and one. Although the blood flow in the right heart is separated from
the left, the two sides of the heart contract in a coordinated manner: first the
atria contract, then the ventricles. Atrium and ventricle of a same half are in
communication between them and the orifice, through which the blood
flows, is controlled by an atrioventricular valve. The function of the
atrioventricular valves is to prevent reflux of blood from the ventricle to the
atrium ensuring unidirectional flow of blood. The mitral valve belongs to
the left half, and controls the flow of blood from the left atrium to the left
ventricle. The tricuspid valve resides, however, between atrium and
ventricle of the right side of the heart. In the ventricular cavities on both the
right and left, there are two other valves, called semilunar valves. Resides
in the left ventricle the aortic valve, which regulates blood flow in the
direction of the left ventricle-aorta; takes place in the right ventricle to the
pulmonary valve, which controls the flow of blood in the direction right
ventricular-pulmonary artery. As the atrioventricular valves, these must also
ensure unidirectional flow of blood. The vessels tributaries, ie those that
lead blood to the heart, "downloading" in the atria. To the left of the heart,
blood vessels are tributaries of the pulmonary veins. For the heart of the
right tributaries are the superior vena cava and the inferior vena cava. The
effluent vessels, ie, those that drain away the blood from the heart, branch
off from the ventricles and those are precisely controlled by the valves
described above. For the heart to the left, the vessel effluent is the aorta. For
the heart to the right, the effluent is the pulmonary artery.

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Blood circulation, starring the heart, is as follows. The right atrium, goes
through the caval veins, blood rich in carbon dioxide and low in oxygen,
which has just sprayed the organs and tissues of the body. The atrium, the
blood goes to the right ventricle and the pulmonary artery take. By this
pathway, the flow of blood reaches the lungs to oxygenate and rid of carbon
dioxide. Without this, the oxygenated blood returns to the heart, the left
atrium through the pulmonary veins. Passes from the left atrium to the left
ventricle, where it is pushed into the aorta, that is, the main artery of the
human body. Once the aorta, the blood goes to spray all the organs and
tissues, exchanging oxygen and carbon dioxide. Depleted of oxygen, the
blood turn into the venous system to return back to the heart, the right
atrium, to "recharge." And so it repeats a new cycle, equal to the previous.
The movements made by the blood occur following a relaxation phase
which follows a phase of contraction of the myocardium, ie the heart
muscle. The relaxation phase is called diastole; the contraction phase is
called systole.
During diastole:
 The heart muscles of the atria and ventricles, both right and left, is
relaxed.
 The atrioventricular valves are open.
 The semilunar valves of the ventricles are closed
 The blood flowing through the vessels tributaries, at first, in the atrium
and then the ventricle. The transfer of blood is not the case in its entirety,
as a share remains in the atrium.
During systole:
It takes place or the contraction of the cardiac muscle. They start the atria
and, subsequently, the ventricles. We speak more accurately, of atrial
systole and ventricular systole:
 The amount of blood that was left in the atria is pushed into the
ventricles.
 The atrioventricular valves close, preventing backflow of blood in
the atria.
 They open the semilunar valves and ventricular muscle is
contracted.

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 The blood is pushed into their effluent vessels: pulmonary veins
(right heart), if it is to oxygenate; aorta (left heart), if it is to reach
the tissues and organs.
 The semilunar valves are closed again after the blood has crossed.
Diastole and systole alternate during the blood circulation and the behavior
of cardiac structures, regardless that the blood is in the right half or the left
half of the heart, are the same. To complete this overview on the heart,
remain to be mentioned two other issues of great importance. The first
concerns how and where does the nervous signal of myocardial contraction.
The second concerns the vascular system that supplies blood to the heart.
The nerve impulse that produces contraction of the heart comes from the
heart itself. In fact, the myocardium is a particular muscle tissue, with the
capacity of autocontrarsi. In other words, the cardiomyocytes are able to
generate by itself the nerve
impulse to the contraction. The
other striated muscles in the
human body instead need to
contract, a signal from the
brain. If you interrupt the nerve
network that leads to this
signal, these muscles do not
move. The heart, however,
presents, at the junction
between the superior vena cava and the right atrium, a natural cardiac
pacemaker, known as the sinoatrial node (SA node). In general, it is called
pacemaker referring to artificial devices, capable of stimulating the
contraction of the heart of patients with certain heart diseases. In order to
properly conduct the nerve impulse, born in the SA node, the ventricles, the
myocardium has other key points: in succession, the generated signal passes
through the atrioventricular node (AV node), the bundle of His, and the
Purkinje fibers.
The oxygenation of cardiac cells is up to the coronary arteries, right and left.
They originate from the ascending aorta. One of their failure results in
ischemic heart disease. Ischemia is a condition, pathology, characterized by
the absence or insufficient blood supply to a tissue. The blood, once
exchanged oxygen with the cardiac tissues, take the venous system of the
cardiac veins and the coronary sinus, thus returning to the right atrium. The
entire vascular network of the heart resides on the surface of the
myocardium, in order to avoid their constriction at the time of cardiac
muscle contraction; situation, the latter, which would alter the blood flow.

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AORTIC VALVE ANATOMY
The aortic valve, or aortic semilunar, is located in the orifice that connects
the left ventricle of the heart and the aorta. It plays a fundamental role:
regulating the flow of oxygenated blood from the heart to organs and tissues,
ensuring unidirectional. At the time of ventricular systole, in fact, the aortic
valve is open and allows the passage of blood into the aorta. A transition
took place, the valve closes, preventing reflux. The mechanism of opening
and closing is dependent on the pressure gradient, the pressure difference
existing between the ventricular compartment and the aorta. in fact:
The aortic valve is composed of the following anatomical elements:
 The orifice tube is delimited from the ring. The surface extent of the
orifice, in the adult, a value between 2.5 and 3.5 cm2.; it’s diameter,
instead, measure 20 mm.
 It is tricuspid, that has three flaps (or cusps) of the lunate form. The
cusps are arranged, on the ring valve, in a staggered manner, such as to
prevent blood reflux, once the valve is closed. The flaps are made up of
loose connective tissue rich in collagen and elastic fibers. As for the
other heart valves, tissue vascularization does not have its cusp, and,
even, a kind of nervous and muscular control.

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STEPS OF AVR - OPEN HEART SURGEY
1. Engraving chest, sternum and
divergence
2. Opening the pericardium and
stripped of the heart and blood
vessels
3. Cannulation of the ascending aorta.
The blood begins to circulate in the
heart-lung machine
4. Opening the right auricle and
cannulation for the machine
5. Preparation cardioplegia
6. Aortic cross-clamping and cardiac
arrest
7. Aortotomia and access to the valve
8. Introduction ring gauge to choose
the right size of the valve
9. Finishing ostium valve prosthesis
to accommodate

14. 13
10. Positioning stitches detached cardinal points ostium valve
11. Suture of the sutures on the ring
where the valve will be implanted
with the device
12. Suture of the prosthesis that will
be positioned ostium prepared
13. Valve positioning and fastening of
points of closure
14. Placing implants in the seat
15. Cut points and elimination
cardioplegia
16. Spontaneous and gradual onset of
cardiac activity
17. With Defibrillation you have the
normal recovery of cardiac

15. 14
TAVR - TRANSCATHETER AORTIC VALVE REPLACEMENT
Successful TA-TAVR is discussed in eight sequential steps: Patient
selection, Preparation, Imaging, Surgical access, Balloon valvuloplasty;
Positioning; Deployment and Surgical closure.
PREOPERATIVE MANAGEMENT
PATIENT SELECTION
Patient selection is the single most important step that can determine success
or failure of TA-TAVR.
PREPARATION
The patient is placed in the supine position and elevation of the left chest is
not routinely required. All electrical cardiogram leads and defibrillator pads
are placed appropriately but out of the way of the anticipated fluoroscopy
sites and allow access to the sternum and left thorax. Lines for continuous
arterial blood pressure monitoring and oximetry are placed before the
patient goes under a general anaesthetic and is intubated. TA-TAVR can be
performed without general anaesthesia, however, very limited experience
has been reported at the present time.
Early in the development of the procedure, the left lung was collapsed to
allow for better visualization of the left ventricular apex. However, it has
subsequently been found that the left lung rarely interferes with exposure of
the ventricular apex. Lung isolation is no longer required. Pulmonary
arterial catheter for continuous cardiac output monitoring is reserved for
patients with poor ventricular function.
For precautionary reasons, an important part of the preparation process is
the presence of perfusionist and a primed cardiopulmonary bypass circuit,
in the event of hemodynamic instability and surgical misadventures.
OPERATIVE TECHNIQUES
IMAGING
TA-TAVR was performed in the operating room using a portable C-arm
fluoroscope. However, the image quality was found to be rather poor to the
point where it was difficult to visualize the aortic valve. A greater quantity
of dye injection at the aortic root was used to better define the native aortic

16. 15
valve (AV) and this was of some concern as a large dye load can be
hazardous in patients with compromised renal function. Moreover, poor
visualization can be a major causative factor for valve malpositioning,
paravalvular regurgitation and embolization. With this in mind, it is strongly
advised that TA-TAVI should only be undertaken in a hybrid operating
room or catheterization laboratory with high-definition fluoroscopic
equipments and multiple monitors. As well, it is imperative that
transesophageal echocardiography (TEE) or intracardiac echocardiography
(ICE) be available to access ventricular, valvular functions and the annular
size. In addition, TEE is an invaluable tool to help with the positioning of
transcatheter valve
stent prior to its
deployment.
Defining the
implant angle,
where the bases of
all three aortic
cusps reside on the
same plane is
crucial to a
successful
implant. An initial
root aortogram
performed with a 7
French (F) pigtail
catheter at the base of the non-coronary cusp at an angle of AP and caudal
10o should guide the operator to define the optimal line of perpendicularity.
Several imaging software systems, such as DynaCT, Innova HeartVision
System and C-THV utilize 3-D rotational angiography to better define the
aortic root anatomy and identify the line of perpendicularity. Preoperative
multi-slice computer tomography (MSCT) can provide valuable
information on annular size and implant angle.

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SURGICAL ACCESS
The left ventricular apex is located by placing the tip of a hemostat on the
patient at the apex location as seen on fluoroscopy. This method has been
found to be reproducible and more useful than palpation for the apex beat,
particularly in patients of high body mass index. Preoperative CT guided or
intra-operative surface echocardiography is used by some groups. Sixth
intercostal space (ICS) is the most common access site, followed by 5th
ICS. Over the previously determined
location of the apex, a 3 cm incision is
made. The incision is made over the
top of the rib to avoid trauma to the
neurovascular bundle. When it is
possible, using the lower ICS is more convenient in terms of a straighter
trajectory to the aortic valve. The left lung, as previously mentioned, does
not usually interfere with the exposure of the left ventricular apex. A soft
tissue retractor, Alexis Retractor is inserted into the incision to retract the
soft tissue without spreading the ribs. This method greatly reduces post-
operative pain.
The pericardium is then incised and opened near the left ventricular apex
and pericardial retraction sutures may aid further exposure. In cases where

18. 17
the patient has a history of previous cardiac surgery, dissection of
pericardial adhesions is avoided.
As with all procedure, transapical
TAVR has an Achilles heel and that is
haemostatic control of the left
ventricular apex. Particular care must
be taken when placing two large
pledgeted orthogonal mattress sutures
using 3-0 MH polypropylene sutures
to obtain full thickness of the left
ventricular wall. Each of the two
mattress sutures are snared and passed
through tourniquets that can be
tensioned at the time of sheath
removal. The sutures are appropriately placed to allow space for the largest
sheath, initially an Ascendra sheath with an internal diameter (ID) of 33 F
sheath and more recently a smaller (24 F ID) Ascendra II Plus delivery
system. The true apex should be avoided, as it is frequently thin and covered
by adipose tissue. A ‘bare spot’ lateral and cranial to the true apex should
be used to avoid catastrophic ventricular rupture.
Rapid ventricular pacing is required for the implantation of balloon-
expandable prosthesis, in order to decrease forward flow during the
valvuloplasty and valve deployment. One unipolar epicardial pacing wire is
placed directly onto the left ventricle and another on patient’s chest wall.
Alternatively, transvenous pacing lead can be implanted into the right
ventricle. Pacing rate of
140 to 200 beat per
minute frequently results
in 1:1 ventricular capture
and lowers the pulse
pressure and forward
flow. The rapid pacing
periods and episodes must be minimized to ensure hemodynamic stability,
especially in patients with depressed left ventricular function and/or non-
revascularized coronary artery disease.

19. 18
Hemostasis of the apex is ensured prior to the administration of
unfractionated heparin to achieve an activated clotting time of greater 250
seconds. A 14-gauge Seldinger needle is positioned in the centre of the
mattress sutures’ square and advanced to enter
the chamber of the left ventricle. The angle of
entry should be pointing toward the right
shoulder, whereby crossing of the native aortic
valve can be easily achieved. Correct placement
can be confirmed by the visualization of bright
red blood spurting with each ventricular
contraction. If oxygenated blood does not spurt
despite advancement of the needle, this suggests
the needle may be in the interventricular septum. Also, the needle could be
inadvertently embedded into the hypertrophied ventricular wall if the angle
of introduction was too obtuse. If pulsatile venous blood is visualized, this
is indicative that the septum has been crossed and the needle has passed into
the right ventricle. Once oxygenated blood is visualized, a soft wire is used
to cross the native aortic valve. A 7F sheath is introduced over the short
wire using Seldinger technique across the AV. A 260 cm, 0.035- inch
Amplatz extra stiff wire is exchanged and maneuvered down the descending
thoracic aorta.
BALLOON VALVULOPLASTY
Balloon valvuloplasty can be performed with a 14 F Cook or the Ascendra
sheath under rapid ventricular pacing. A 3 cm, 20 cc BAV balloon from
Edwards LifeSciences is used for all cases
regardless the size of the annulus. BAV
facilitates the crossing of the stenotic AV and
retrieval of the transcatheter valve if it is
accidentally advanced past the native valve.
Further, BAV improves the aortic valve area
and allows flow around the valve stent during
positioning, thus minimizing hemodynamic
instability. BAV also rehearses the
deployment steps, allowing synchronization
of the team.
Close observation of the movement of the calcified leaflets relative to the
coronary Ostia during BAV may help to exclude patient with high-risk

20. 19
anatomy for coronary occlusion. A root aortogram can be performed with
an inflated balloon in situ to better define the structures.
POSITIONING
The Edwards SAPIEN balloon expandable transcatheter valve is
constructed of trileaflet bovine pericardium on a metal stent. It is crimped
onto the delivery balloon. The correct orientation of the transcatheter valve
with the Dacron ring at the base of the valve on the ventricular outflow side
and open stent on the aortic side must be ensured. After engaging the
delivering system, the valve is advanced beyond the tip of the Ascendra
sheath under fluoroscopic guidance.
Withdrawal of the pusher catheter is
then carried out. The SAPIEN valve
is positioned within the native AV.
The SAPIEN prosthesis is ideally
placed 1/3 below the base of aortic
sinuses, the bottom of the valve stent
positioned ventricularly relative to
the line of perpendicularity with the
aide of repeat aortic root angiograms. TEE provides additional images that
further refine the positioning. Aligning the ventricular end of the valve stent
to the aorto-mitral fibrous curtain, the “hinge point’ of the anterior leaflet
of the mitral valve, confirms the ideal landing zone. If accurate positioning
cannot be achieved due to brisk cardiac motion, rapid pacing with root
injections may assist in positioning.
DEPLOYMENT
It is extremely important to ensure
accurate positioning of the valve prior to
its deployment to avoid malpositioing,
embolization and significant perivalvular
leak. Once acceptable positioning is
confirmed using echocardiography and
fluoroscopy, the pigtail catheter is
withdrawn to the ascending aorta, the
pacing protocol is again initiated and the
valve is slowly deployed. During
deployment, fine adjustment can be made
to ensure optimal placement. Full

21. 20
emptying of the inflation syringe and maintaining full pressure ensures
symmetric deployment and prevents stent recoiling. The balloon is quickly
deflated and pacing is ceased. The balloon is pulled back out of the valve
stent into the delivery sheath, preventing interference with leaflet function.
Once the valve is deployed, echocardiography reports on the stability,
location and function of the valve stent, and the degree of perivalvular
regurgitation. If valve position is satisfactory and more then moderate
degree of perivalvular regurgitation exists, a second attempt with slight
higher balloon inflation volume may be attempted. If the degree of central
regurgitation through the valve is difficult to evaluate with the Amplatz wire
across the valve, it too is withdrawn into sheath. Completion aortogram is
seldom perform to minimize the dye load that may adversely effect renal
function.
SURGICAL CLOSURE
With systolic pressure less than 100 mmHg, the delivery sheath is removed
with snugging of the mattress sutures. Then
the other orthogonal mattress suture is
subsequently tied. Persistent hypertension can
be controlled with ventricular pacing at a rate
of 100 to 140 bpm. Any blood collections are
aspirated from the left chest and local
bupivacaine is injected into the intercostal
muscles. A small-bore chest drainage tube
brought out through a small stab wound is left
behind in the left chest. The intercostal
muscles are approximated and the skin closed
with absorbable subcuticular suture.
CONCLUSION
Within the last decade, transcatheter aortic valve replacement (TAVR) has
come from relative obscurity to become a procedure that is practiced at most
major health centres worldwide and the technical details of this procedure
have been described by many. The rapid adoption of TAVR in medical
practice makes it one of the fastest therapeutic modalities incorporated and
evaluated by randomized control trial. Transfemoral (TF-TAVR) retrograde
and transapical (TA-TAVR) antegrade approaches were the most widely
practiced. TA-TAVR is the preferred procedure where the peripheral access

22. 21
is limited due to size, calcification and torturosity. TA-TAVR provides a
more stable platform for TAVR, due to the more direct and shorter distance
to the native aortic valve. Access via the subcalvian artery and ascending
aorta are emerging to be viable alternatives. Procedural technique can be
very important in high-risk patients and remains among the few modifiable
factors. Therefore, it is worthwhile to describe the intricacies of the TA-
TAVR approach, with the aid of photographs. The technique described is
intended for transapical implantation of the SAPIEN transcatheter valve
using the Ascendra delivery system.

23. 22
FAQ
WHAT CAUSES A FAILURE OF THE AORTIC VALVE?
The aortic valve can not work for various reasons. For example, may be
abnormal from birth (congenital aortic valve), or may become ill with age
(acquired aortic valve disease).
The most common congenital abnormality is a bicuspid aortic valve. The
normal aortic valve has three flaps, but a bicuspid valve has only two.
Therefore, it may not open or close completely. The bicuspid aortic valve is
a common abnormality and is present 1-2% of the population. For frequency,
it is the second leading cause of aortic disease that requires surgical
treatment. such valves can function normally for years before they begin to
be dysfunctional (stenotic and / or insufficient). People with a bicuspid
aortic valve require antibiotic prophylaxis before interventions to the teeth
but are not generally required other special precautions in addition to
periodic monitoring by a cardiologist qualified. The most common cause of
aortic disease that requires treatment surgery is called "senile aortic
calcification." The valve is namely ruin with age. When a valve begins to
deteriorate, the body calcium deposits on it for unknown reasons. The
football narrows diameter and restricts the movement of the valve leaflets.
This may hinder the valve opening (causing stenosis) or closing (causing
insufficiency or regurgitation). Less common causes of valve disease aortic
diseases of the ascending aorta, the main vessel blood that comes out from
the heart and which carries the blood to the rest body: the aneurysm,
dissection and Marfan syndrome.
THERE ARE SIGNS OF A FAILURE OF THE ALARM AORTIC VALVE?
Alteration of the aortic valve can cause a variety of symptoms, which
include shortness of breath, chest pain (angina pectoris), dizziness and loss
of consciousness (fainting). A valve stenosis causes an increase of the work
that the heart has to do to pump blood around the body. a failure of the valve
results in a return of blood in the heart after it has been pumped out. The
heart muscle must therefore pump more blood to go forward, even one that
is returned back. All of these conditions can cause symptoms super job of
heart failure, such as shortness of breath, which at the beginning can be
appreciated only under stress, but that later, with the progression of the
disease, may also occur with activity light or at rest. Many patients can not
sleep lying in bed or can wake up to the shortness of breath. Another sign
of heart failure, which can occasionally appear, it is the swelling of the feet,

24. 23
particularly evident in the late afternoon or evening, although other
conditions such as varicose veins can cause such disorder. The super work
that the heart has produced, can also cause pain angina pectoris or chest
similar to the symptoms of a heart attack. It can be difficult to tell the
difference between a disease and valvular stenosis of the blood vessels of
the heart (arteries coronary arteries). The disease of the aortic valve can
therefore cause dizziness, light-dizziness or even fainting periodicals.
HOW DO I KNOW IF I HAVE TO BE AT WORK AORTIC VALVE?
The decision to proceed with surgery should be taken with his medical team
is usually composed of the cardiologist and by the cardiac surgeon. The His
doctors probably base their recommendations on her symptoms and the
results of some tests including an echocardiogram and cardiac
catheterization times. An echocardiogram allows you to see an enlargement
of the heart and can help to measure the degree of stenosis or insufficiency.
A Cardiac catheterization provides similar information, but it can also
identify possible stenosis of the coronary arteries.
THERE ARE DIFFERENCES BETWEEN IMPLANTS AND MECHANICAL
ORGANIC?
Today there are numerous excellent prosthetic valves mechanical. Most
surgeons have a preference for a specific valve in relation to some of the
technical factors (for example: how they apply in the home, as did the suture
ring, etc.). Although from the point of view of the patient is small the
eventual difference between the various models. The main advantage of
mechanical valves is their excellent lifespan. From a practical point of view,
never wear. The main disadvantage is that there is a tendency of blood to
clot on all mechanical valves. Consequently, patients with such valves must
take anticoagulants or "blood thinners" for the rest of their lives. So there is
a small but well-defined risk of blood clotting, which can cause the
prosthesis stroke. There is a large variety of biological valves that can be
used to replace a diseased valve. They all have in common a reduced risk
of formation of blood clots, but all are less durable than mechanical valves.
Past a certain time, all will be consumed. The choices in this category
include the xenograft, valves made from animal tissue (most of the times of
pig aortic valves or valves "built" with pericardium cattle), the homograft
or allograft valves prepared from cadavers human, and l '"pulmonary
autograft", a self transplant, their valve moved from the pulmonary artery
on the right side of the heart, the seat Aortic on the left side.

25. 24
The decision on the type of valve to be used should be taken into accordance
with his cardiologist and cardiac surgeon. Ultimately the choice depend on
the preferences of the patient, his lifestyle and individual risk determined
by age and other medical conditions.
HOW IS THE SURGERY PERFORMED?
The replacement of the aortic valve is an intervention that is performed only
by the cardiac surgeon. Is performed under general anesthesia general.
Before being asleep are inserted cannuline in certain veins of the arm, for
the infusion of drugs, and in artery for continuous measurement of blood
pressure. The traditional technique requires a longitudinal aperture
(vertical) of the anterior wall of the chest through the breastbone that is cut
into two parts. This incision is called a sternotomy vertical midline. Through
this opening, the surgeon can see all your heart and the ascending aorta. The
surgery requires that the patient is connected to the machine heart-lung. To
do this, two cannulas are inserted, one in the the upper part of the ascending
aorta and the right atrium. They carry the blood from the patient to the
machine, where it is enriched with oxygen, and vice versa. Started the extra
corporeal circulation, the heart can be stopped with a special blend of
chemicals call cardioplegia.
At this point, the aorta is opened, the diseased valve removed and the His
place was inserted a prosthesis (mechanical or biological). and then the
aorta is closed. Just receive back the blood, the heart begins spontaneously
to contract. The patient can then be removed from the machine.
WHY I NEED SURGERY?
The aortic valve is the valve out of the left side of the heart. It opens during
systole (when the ventricle contracts and pushes blood into the aorta and the
rest of the body). When the aortic valve is too narrow (stenotic), the
ventricle must work hard to push the blood around the body. This extra-
work consumes considerable amounts of energy and ultimately requires a
blood flow in more to nourish the heart itself. If there is a sufficient arrival
of the blood, the heart becomes ischemic with resulting in anginal chest pain.
Aortic stenosis is usually progressive and gets worse with time. When the
valve becomes very narrow, the heart has to work harder and harder until
that an certain point no longer able to compensate. Appear as episodes of
low blood pressure (hypotension crises), syncope (loss of consciousness),
congestion and pulmonary edema. Even when the aortic valve is insufficient
(loses), the heart works harder and you create the same problems. The

26. 25
ventricle must pump more blood with each contraction to produce the same
thrown forward. This creates a condition called overload volume. The heart
can compensate for this overload for many months or even years, provided
that the failure to develop slowly. By the time the heart starts to break down
and appear to lack breath and weakness. The possible benefits could be the
disappearance of the anginal symptoms, heart failure and syncope. The
chances of successful treatment in the absence of complications, are 95%
(failure rate of 5%).
ALTERNATIVES TO SURGERY
Are there alternatives to surgical treatment and that the facility valvular
trans-apical (TA-TAVI), namely the implantation of an endoprosthesis tube
through a cannulation of the apex of the heart with a mini access chest or
with the introduction of an endoprosthesis valve through the femoral artery
in the groin catheterization. These methods, however, at present, are
indicated only for patients with severe impairment of the general condition
or patients terminals, that is not amenable to conventional treatment.
RESULTS OF TREATMENT FAILURE
The predictable outcome of not treating are worsening progressive heart
failure and angina with an increase functional limitations, increased
frequency of episodes syncopal and the possibility of cardiac death.
WHAT 'THE RISK OF SURGERY?
The risk cardiac surgery depends on the conditions, the general conditions,
the presence of other comorbidities and functional status of the major organs
and body systems. Among these are:
 circulatory failure can not be controlled with medication, for which
must resort to mechanical systems support.
 sudden occlusion of a coronary by-pass with the eventual need for a
new surgery;
 malfunction of prosthetic valve;
 heart attack directly associated with the transaction;
 paralysis (temporary or permanent) in the arms and / or legs (for
example due to an insufficient blood supply);
 complications of the gastro-intestinal tract;

27. 26
 cerebral complications (results in impaired speech and movements
up to coma) caused by a blood supply defective due to poor
circulation or blood clots;
 thrombosis, embolism (blood clots and subsequent vessel
occlusion);
 bleeding: from surgical sutures and / or from abnormal coagulation
of the blood;
 infection and suppuration intractable arrhythmias or forms that may
require further medicines, or the implantation of a pacemaker;
 Pouring liquid into the pleural cavity and / or in the pericardium,
which must be drained;
 shortness of breath due to paralysis of the diaphragm;
 broncho-pneumonic complications.
WHAT WILL MY CONDITION AFTER REPLACING AORTIC VALVE?
After successful aortic valve replacement, patients can expect to return
quickly to the conditions preoperative. As a result of their condition should
definitely improve. The anticoagulant ("blood thinning") with a drug
(Sintrom or Coumadin) should be prescribed for 2-3 months in patients with
biological prosthesis, for the whole life in those with valve mechanics.
When surgical wounds will be healed, there will be few or no restrictions
on its activity.

28. 27
ARTICLE 1 – SURGICAL TREATMENT OF AORTIC VALVE ENDOCARDITIS
ABSTRACT
Endocarditis of the aortic valve is a surgical
operation that is applied since 1965 This article
presents a retrospective study of all the operations
and the results obtained in 174 aortic valve
replacements affected by endocarditis, in 26 years
of business in Kartal Kosuyolu Heart and Research
Hospital in Istanbul. 282 interventions were
performed, of which 230 have been replacements of aortic valves (with and
without endocarditis). The hospital mortality was 15.5% (27 cases). The
survival rate for 10-15 years after surgery was equal to 74.6 + 3.7% (in
patients with a reduced cardiac output) and to 61.1 + 10.3% (for patients
who have had a cardiac arrest). This study found that the operation has a
significant mortality and risk factors are: emergency operations, female
gender, renal failure and reduced cardiac output. The risk of recurrence and
the need for new operations is low.
Kartal Kosuyolu Heart and Research Hospital, Istanbul - Turkey

29. 28
ARTICLE 2 - AORTIC STIFFNESS IS AN INDICATOR OF COGNITIVE
DYSFUNCTION
ABSTRACT
This article presents a study on patients had cognitive dysfunction, after
operation of the AVR (Aortic Valve Replacement) for Aortic Stenosis (AS).
These disorders are frequent in patients operated on at the aortic valve due
to the risks associated with the surgery, which are: the systemic
inflammatory response syndrome, hypoperfusion, microembolization. Even
in patients undergoing "successful interventions" were presented
postoperative cognitive problems. In the face of these data, it was decided
to evaluate whether aortic stiffness is related to cognitive dysfunction in
patients undergoing surgery for aortic
stenosis. The aortic pulse wave
velocity (PWV) was used as a
measure of aortic stiffness and
cognitive function was assessed using the computerized Cambridge
Neuropsychological Test Automated Battery (Cantab). Patients with normal
PWV were: higher mental retardation, visual sustained attention and
executive function comparable to patients with high PWV. The immediate
memory and decision-making were similar in the two groups. After surgery,
the improvement of cognitive function was more pronounced in patients
with higher PWV compared to patients with normal PWV. The conclusion
is that the intervention AVR can not be associated with an effect on
cognitive process. The PWV could be useful as an additional marker of
cognitive function before and after surgery for AS.
St. Mary's Hospital, London - England

30. 29
ARTICLE 3 – “FAST-IMPLANTABLE” AORTIC VALVE
ABSTRACT
This article presents a new type of valve that can be implanted during an
intervention with concomitant mitral valve replacement. Two bioprosthetic
heart valves may interfere for their design or for space dimensions. With the
new valve Intuity (who has a stent under the ring) there is no interference
with an existing mitral valve. The valve
has been tested on pigs before and then
after signing the informed consent, two
patients. The first was a woman of 82 years
of which have been replaced both valves,
the aortic and mitral stenosis, without
interference observed on chest
radiographs. The second case was also
replaced both valves via two venous grafts
without presenting postoperative
interference. In the light of these results it
has been claimed that the valve Intuity is
much faster to implant (does not need all the stitches of the prosthesis
standard) and its plant does not increase the risk of displacement of the
mitral valve. The time to plant is 8-1o minutes and this significantly lowers
the probability of an ischemic cardiac arrest.
University of Lausanne, Lausanne - Switzerland

31. 30
ARTICLE 4 - RETROGRADE CARDIOPLEGIA ADMINISTRATION
ABSTRACT
This article emphasizes the importance of the administration of retrograde
cardioplegia in a particular case. The Routes of administration of
cardioplegia are three:
• Aortic Bulb: seat of election, with the exception of aortic insufficiency
because refluirebbe in the ventricle;
• Coronary Osti: using this access route in the case of aortic
insufficiency;
• Breast coronary artery (retrograde): you use this access route even
when the coronary ostia are obstructed or otherwise there is a multi-
axial obstructive coronary artery disease.
The coronary sinus can be reached directly with a video-assisted
cannulation and at pressures lower than 40 mmHg, or indirectly through the
right atrium (little used because it would cause excessive dilation of the
atrium or the right ventricle).
In this case the patient, 66, had been admitted into the local clinic for the
treatment of aortic stenosis. Angiography showed variations in coronary
narrowing. At the same time it was found that the anterior branch had a
separate start dall'ostio descending artery. Because of the complex
anatomical situation of the aortic valve was decided to change the strategy
to protect the myocardium against ischemia. The procedure was performed
in moderate hypothermia at 32 ° C and the heart was stopped with cold
retrograde cardioplegia. The result showed no postoperative ischemic
damage in the patient.
Akademicki Szpital Kliniczny, Wrocław - Poland

32. 31
ARTICLE 5 – MID-TERM RESULTS FOR AORTIC ROOF REPLACEMENT
ABSTRACT
This article shows the results of 201 interventions for aortic root
replacement with biological prosthesis and stent. The patients had a mean
age of 66 years old and had
undergone surgery for:
annuloectasia or aortic aneurysm
of the ascending aorta with
concomitant valve endocarditis.
The hospital mortality was 4.5%
and the rate of cardiac mortality
related to the intervention, after
1-5 years, 3-6%. No patient
presented over the years
thromboembolic events. The 1%
of patients presented a slight
structural deterioration of the
valve without clinical symptoms.
In light of these results it can be stated that in the medium term, the aortic
root replacement with biological prosthesis self-assembling is interesting.
The hemodynamic results are excellent and the need to redo the operation
is remarkably low. The long-term results will clarify fully the real risks of
surgery.
University Hospital Berne, Berne - Switzerland

33. 32
ARTICLE 6 – PERCUTANEOUS AORTIC VALVE REPLACEMENT
ABSTRACT
To be eligible for the TAVR is a
variable number of patients. 30% of
patients with severe aortic stenosis
who require appropriate action, not
receive it. Given the aging of the
global population, patients who will
need TAVR will be more and more.
Clearly, the choice between TAVR
and AVRbyOS will be dictated mainly by the costs and organization of each
country. On the one hand you have a very high risk of doing AVSbyOS in
cases of emergency and the other with the TAVR is likely a left bundle
branch block. In addition, patients who need a pacemaker after the operation
are those made with TAVR; the same ones who have the most frequent
postoperative stroke. Instead, ischemic defects are more frequent in patients
operated with AVRbyOS because the aorta is manipulated. It can be
concluded that on both sides there are risks to consider but lacks a
randomized clinical trial to know the follow-up of patients 10-15 years after
surgery. When these data will be collected you will have the chance to make
a change of direction towards the TAVR intervention that is less invasive
and with fewer postoperative complications.
Hospital Universitario “Fundación Favaloro” - Argentina

34. 33
BIBLIOGRAPHY
 Autori vari, Trattato di Anatomia Umana, Volume I e II, Edizione 2009,
Edi-ermes.
 Guyton A. e Hall J. E., Fisiologia Medica, Edizione 2010, Elsevier.
 Nelson D. L. e Cox M. M., I principi di Biochimica di Lehninger, Edizione
2010, Zanichelli.
 Andreoli, Carpenter, Griggs, Benjamin, Cecil Essential of Medicine,
Edizione 2007, Elsevier.
SITOGRAPHY
 PUBMED:
http://www.ncbi.nlm.nih.gov/pubmed
 NEW ENGLAND JOURNAL OF MEDICINE:
http://www.nejm.org
 CARDIO EXPERT CHANNEL:
http://www.youtube.com/channel/UCeaM0YzToLcfeCiBkJQCqhA
 http://www.ucl.com
 http://www.cardiochirurgia.org/sva.html
 http://my.clevelandclinic.org/services/heart/disorders/valvetreatment/aort
icvalvesurgery