Posterior approach aortic root enlargement in redo aortic

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Posterior approach aortic root enlargement in redo aortic

  1. 1. Posterior Approach Aortic rootPosterior Approach Aortic root enlargement in Redo aortic Valve;enlargement in Redo aortic Valve; Risk factorsRisk factors.. Mohamed HelmyMohamed Helmy M.D , Ass. Professor cardiothoracic surgeryM.D , Ass. Professor cardiothoracic surgery Kasr el Einy univ.Kasr el Einy univ. Osama Abouel Kasem M.DOsama Abouel Kasem M.D Soleiman abdelhay M.D.Soleiman abdelhay M.D. Department of cardiothoracic surgery Faculty of medicineDepartment of cardiothoracic surgery Faculty of medicine Cairo University.Cairo University.
  2. 2. The main goal of aortic valve replacementThe main goal of aortic valve replacement (AVR) for aortic stenosis is to releive the(AVR) for aortic stenosis is to releive the pressure and volume overload on the leftpressure and volume overload on the left ventricle, allowing regression of theventricle, allowing regression of the ventricular mass.ventricular mass.
  3. 3. it is not always possible to avoid patient–it is not always possible to avoid patient– prosthesis mismatch (PPM) usingprosthesis mismatch (PPM) using standard implantation procedures,standard implantation procedures, particularly in small patients and in thoseparticularly in small patients and in those with a large body surface area (BSA).with a large body surface area (BSA).
  4. 4. Is a small annulus an inconvenience? Indicators: Earlymortality Hemodynamic impairment Functional status: NYHA Re-operations Late mortality
  5. 5. Small valves effect Hemodynamic parameters Gradient regression Incomplete in 19 Gradients increase with time in mismatch Mass regression Not significant in 19mm. Better in ≥21mm. Sim EK, Orszulak TA, Scaff HV and Shub C. Influence of prosthesis size on change in left ventricular mass following aortic valve replacement. European J Cardio Thorac Surg1994;8:293-7. (Mayo group).
  6. 6. Hemodynamic parameters Cardiac index when EOA< 0,85cm2/m2 Decreases after 3 years . Hemodynamic continues to deteriorate with time. P, Pibarot Dumesnil JG, Lemieux M, Cartier P, Metras J, Durand LG. Impact of prosthesis-patient mismatch on hemodynamic and symptomatic status, morbidity and mortality after aortic valve replacement with a bioprosthetic valve. J of Heart valve disease 1998;2:207-16.
  7. 7. Mismatch and negative effect on Symptomatic improvement Less NYHA improvement in mismatch p< 0,009 independently to other predictors. P, Pibarot Dumesnil JG, Lemieux M, Cartier P, Metras J, Durand LG. Impact of prosthesis-patient mismatch on hemodynamic and symptomatic status, morbidity and mortality after aortic valve replacement with a bioprosthetic valve. J of Heart valve disease 1998;2:207-16
  8. 8. Although ARE procedures are 30 years old, It isAlthough ARE procedures are 30 years old, It is practiced by only a few surgical groups.practiced by only a few surgical groups. The largest series (The largest series (nn = 669) belongs to the= 669) belongs to the Toronto groupToronto group In their first report (1997In their first report (1997), they), they have shown that ARE increased the cross-clamphave shown that ARE increased the cross-clamp time, the rate of re-operation for bleeding andtime, the rate of re-operation for bleeding and the operative mortality rate (7.2% vs 3.5%),the operative mortality rate (7.2% vs 3.5%), compared with patients who underwent AVRcompared with patients who underwent AVR alone.alone. ThoracThorac CardiovascCardiovasc Surg.Surg. 1979 Sep;78(3):402-12.1979 Sep;78(3):402-12. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitralPatch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. New operative technique.leaflet. New operative technique. ManouguianManouguian SS,, Seybold-Seybold-EptingEpting WW..
  9. 9. After this initial negative experience, thisAfter this initial negative experience, this group presentedgroup presented new results in 2007new results in 2007,, revealing a steeper decline in the mortalityrevealing a steeper decline in the mortality rate (down to 2.9%), probably a result ofrate (down to 2.9%), probably a result of the growing experience.the growing experience.
  10. 10. Freedom from valve-related mortality 75±5% ‘mismatch’ 84±2% ‘normal’. (227 ‘mismatch’ / 2981pts) Rao V, Jamieson WR, Ivanov J, Armstrong S, David TE. Prosthesis- patient mismatchaffects survival after aortic valve replacement. Circulation 2000; 102(19 Supp 3): III5-9,)(Toronto)
  11. 11. Why ENLARGE the annulus? Small valves not ideal in large men BSA > 1,9m2 Hemodynamics are not optimal with small valves and further deteriorate over time Occasionally have to re-operate patients who as adults received
  12. 12. Who to ENLARGE? ≤19 mm aortic annulus BSA 1,9m2 IEOA 0,85cm2/m2.
  13. 13. Operative mortality? Equal to normal procedure when done ‘routinely’ 114/657pts; Mean age 72±11 (Luis J Castro, JM Arcidi, AL Fisher, VA Gaudiani. Routine enlargement of thesmall aortic root: a preventive strategy to minimize mismatch. Ann ThoracSurg 2002;74:31-36.)
  14. 14. Long-term results Survival at 10 yrs 85,7% ‘enlarged’ versus 62,7% ‘small valves’ Freedom valve related events81% versus 58,8%. (Kitamura M, Satoh M, Hachida M, Endo M, Hashimoto A, Koyanagi H. Aortic valvereplacement in small aortic annulus with or without annular enlargement. Journal of Heart Valve disease 1996: Suppl 3: S 289-93).
  15. 15. Sudden late death increases in 19mm with BSA≥1,9 Kratz JM, Sade RM, Crawford FA, Crumbley AJ, Stroud MR. The risk of small St. Jude aortic valve prostheses. Ann Thorac Surg 1994;57:1114-1118
  16. 16. MethodsMethods:: We reviewed perioperative outcomesWe reviewed perioperative outcomes among patients undergoing redo aorticamong patients undergoing redo aortic valve replacement with aortic rootvalve replacement with aortic root enlargement at our institution betweenenlargement at our institution between January 2008 and December 2012. RiskJanuary 2008 and December 2012. Risk factors for operative death were evaluatedfactors for operative death were evaluated by means of multivariable analysis.by means of multivariable analysis.
  17. 17. Total of 25 patients 13 males and 12Total of 25 patients 13 males and 12 females had repeated aortic valvefemales had repeated aortic valve replacement , mean agereplacement , mean age 3636.64 ± 4.10..64 ± 4.10. TheThe indicationsindications for reoperation were:for reoperation were: prosthetic valve malfunction due toprosthetic valve malfunction due to patient valve mismatch , pannus, infectivepatient valve mismatch , pannus, infective endocarditis and bioprosthetic valveendocarditis and bioprosthetic valve degeneration.degeneration.
  18. 18. The size of explanted prostheses rangedThe size of explanted prostheses ranged between 19–21 mm while the size of thebetween 19–21 mm while the size of the implanted prostheses ranged betweenimplanted prostheses ranged between 21–25 mm .21–25 mm . Root enlargement was accomplished byRoot enlargement was accomplished by Manougian technique.Manougian technique.
  19. 19. Table 1: Demographic data Variables Number of patients (%) n=25 Deaths (%) n=2 P value Mean age(y) ±SD 36.64 ± 4.10 Male (%) 13(52.00) 1(7.70) 0.549 NYHA class (%) 1 0(0.00) 0(0.00) 2 3(12.00) 0(0.00) 3 14(56.00) 1(7.14) 4 8(32.00) 1(12.50) 0.026* Diabetic patients (%) 8(32.00) 1(12.50) 0.072 Chi- square test p<0.05
  20. 20. Table 2: Preoperative echocardiography. Echocardio graphy Number of patients (%) n=25 Deaths (%) n=2 P value LVED≤ 5.30 cm 13(52.00) 0(0.00) LVED> 5.30 cm 12(48.00) 2(16.67) 0.841 LVES ≤ 3.9 cm 15(60.00) 0(0.00) LVES> 3.9 cm 10(40.00) 2(20.00) 0.317 EF%≤ 50% 17(68.00) 2(11.76) EF% >50% 8(32.00) 0(0.00) 0.072
  21. 21. Table : Operative details Variables Number of patients (%) n=25 Deaths (%) n=2 P value Cross clamp ≤ 90 min 17(68.00) 0(0.00) >90 min 8(32.00) 2(25.00) 0.072 Bypass time ≤ 120 min 21(84.00) 0(0.00) >120 min 4(16.00) 2(50.00) 0.001*
  22. 22. Echocardiograp hy Number of patients (%) n=25 Deaths (%) n=2 P value LVED≤ 5.30 cm 13(52.00) 0(0.00) LVED> 5.30 cm 12(48.00) 2(16.67) 0.841 LVES ≤ 3.9 cm 15(60.00) 0(0.00) LVES> 3.9 cm 10(40.00) 2(20.00) 0.317 EF%≤ 50% 17(68.00) 2(11.76) EF% >50% 8(32.00) 0(0.00) 0.072
  23. 23. How to ENLARGE the annulus? Manougian Manougian technique
  24. 24. Surgical TechniqueSurgical Technique A transverse aortotomy was made and after explanting the oldA transverse aortotomy was made and after explanting the old valve , excessive fibrotic tissue was debrided ,If the annulus didvalve , excessive fibrotic tissue was debrided ,If the annulus did accommodate a 19-mm obturator or less, root enlargement wasaccommodate a 19-mm obturator or less, root enlargement was undertaken.undertaken. The aortotomy incision was extended along the commissureThe aortotomy incision was extended along the commissure between the left coronary and the noncoronary sinuses, across thebetween the left coronary and the noncoronary sinuses, across the centre of the fibrous origin of the anterior mitral leaflet 1.5 to 2 cm .centre of the fibrous origin of the anterior mitral leaflet 1.5 to 2 cm . A Dacron patch was then used in all the patients to enlarge theA Dacron patch was then used in all the patients to enlarge the aortic annulus with continuous 4/0 Proline sutures .The aortic rootsaortic annulus with continuous 4/0 Proline sutures .The aortic roots were enlarged by 2 to 4 mm . The appropriate valve sizerswere enlarged by 2 to 4 mm . The appropriate valve sizers
  25. 25. ResultsResults The total number of hospital mortality wasThe total number of hospital mortality was 2 cases (8%),due to low cardiac output.2 cases (8%),due to low cardiac output. Rexploration was undertaken in the 3Rexploration was undertaken in the 3 cases due to bleeding with proper controlcases due to bleeding with proper control of bleedingof bleeding
  26. 26. ConclusionConclusion Aortic root enlargement using posterior approach does not increase the surgical risk and can be done safely.
  27. 27. Limitation of the studyLimitation of the study The most important limitation of theThe most important limitation of the study was the small number of patientsstudy was the small number of patients and failure to provide long-term follow-up.and failure to provide long-term follow-up. We encourage prospective operativeWe encourage prospective operative strategies to minimize predictablestrategies to minimize predictable mismatch,mismatch,

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