The Aortic Valve and The Aortic Valve and The Aortic Root in The - PowerPoint PPT Presentation

The Aortic Valve and The Aortic Valve and The Aortic Root in The Aortic Root in Type A Aortic Dissections Type A Aortic Dissections Optimal Surgical Surgical Optimal Technique Technique

Type A aortic aortic dissection dissection Type A Objectives of of surgical surgical repair repair Objectives � Replace Replace the the segment segment of of ascending ascending � aorta where where the the intimal intimal tear tear occured occured aorta � Treat Treat aortic aortic regurgitation regurgitation � � Eliminate Eliminate any any antegrade antegrade flow flow in in the the � false lumen lumen false � Keep Keep the the patient patient ALIVE ALIVE �

Type A aortic aortic dissection dissection Type A Surgical Technique Technique Surgical � Emergency Emergency surgery surgery � � « « Open Open » » distal distal anastomosis anastomosis � • Avoid Avoid aortic aortic Xclamp Xclamp • • Inspect Inspect the the Transverse Transverse Ao Ao Arch Arch (30% (30% • intimal tear tear) ) intimal � Antegrade Antegrade flow flow � � AORTIC ROOT & VALVE ? AORTIC ROOT & VALVE ? � ….. Canulation of the Axillary Artery

Type A dissection Type A dissection Disease of of the the aortic aortic valve valve Disease � « « de de novo novo » » aortic aortic regurgitation regurgitation due to due to � detachment of of one one or more commissures or more commissures detachment and prolapse prolapse of of the the valve valve and � Preexisting Preexisting disease disease of of the the aortic aortic valve valve � and/or /or root root prior prior to to the the dissection dissection and

How was was the the aortic aortic valve valve How PRIOR TO dissection ? dissection ? PRIOR TO Past cardiac cardiac history history � Past � Prior echo echo studies studies � Prior � Preoperative echo echo � Preoperative � Operative findings findings � Operative �

True lumen False lumen Intimal flap Intimal tear Aortic regurgitation

Status of of Aortic Aortic VALVE & VALVE & Status ROOT PRIOR PRIOR to Dissection to Dissection ROOT � Aortic Aortic Valve Valve � Aortic Aortic Root Root � � • Normal Normal • Normal Normal • • • Bicuspid Bicuspid • Dilated Dilated • • • Calcified Calcified • • Aortic Aortic • Regurgitation Regurgitation

Bicuspid aortic Valve Normal aortic Root Commissure Cusp

DILATED Aortic Root Aortic Regurgitation

commissures Normal Aortic Valve

False lumen Intimal flap The commissure is detached and the cusp prolapse in the LV Aortic Regurgitation In Aortic Dissection

Surgical Techniques Techniques Surgical Aortic Root Root & & Aortic Aortic Valve Valve Aortic � Replace Replace the the ascending ascending aorta aorta (GRAFT) (GRAFT) � � Nothing Nothing on on the the valve valve and and root root � � Resuspend Resuspend the the valve valve � � Replace Replace the the valve valve � � Replace Replace the the valve valve and and root root ( (Bental Bental) ) � � Replace Replace the the root root (valve (valve sparing sparing) ) �

Surgical Techniques Techniques Surgical Aortic Root Root & & Aortic Aortic Valve Valve Aortic � Replace Replace the the ascending ascending aorta aorta � � Nothing Nothing on on the the valve valve and and root root � � Resuspend Resuspend the the valve valve � � Replace Replace the the valve valve � � Replace Replace the the valve valve and and root root ( (Bentall Bentall) ) � � Replace Replace the the root root (valve (valve sparing sparing) ) �

Reconstruction of the distal aortic segment (Obliterate the false lumen) (Resection of the segment that carries the intimal tear)

Replacement of the ascending aorta (supra coronary) Nothing on the valve and the root

Surgical Techniques Techniques Surgical Aortic Root Root & & Aortic Aortic Valve Valve Aortic � Replace Replace the the ascending ascending aorta aorta � � Nothing Nothing on on the the valve valve and and root root � � Resuspend Resuspend the the valve valve and and reconstruct reconstruct the the � sinus sinus � Replace Replace the the valve valve � � Replace Replace the the valve valve and and root root ( (Bentall Bentall) ) � � Replace Replace the the root root (valve (valve sparing sparing) ) �

Dissection of the Aortic Root Non-coronary sinus The intimal flap The commissure False lumen Is detached

Dissection of the Aortic Root Non-coronary sinus Intimal flap Detached commissure Commissure reattached False lumen

Reconstruction of the aortic root Occlusion of the false lumen Resuspension of the commissures Le faux chenal

Reconstruction of the aortic root

Surgical Techniques Techniques Surgical Aortic Root Root & & Aortic Aortic Valve Valve Aortic � Replace Replace the the ascending ascending aorta aorta � � Nothing Nothing on on the the valve valve and and root root � � Resuspend Resuspend the the valve valve � � Replace Replace the the valve valve � � Replace Replace the the valve valve and and root root ( (Bental Bental) ) � � Replace Replace the the root root (valve (valve sparing sparing) ) �

Normal aortic valve Aortic valve replaced

Root Replacement (Bental)

Ascending Ascending Root Aorta & Aortic replacement Aorta Valve

Valve sparing operation remodelling (Yacoub) 1 3 1 3 2 2

Valve sparing sparing operation operation Valve reimplantation (David) (David) reimplantation

Surgery for Type A for Type A Surgery dissections dissections Operative Mortality Mortality Operative 10 – – 26 % 26 % 10

Long- -term term effectiveness effectiveness Long Sabik et al. J Thorac Cardiovasc Surg 2002

Long- -term term study study Long (Cleveland Clinic Clinic) ) (Cleveland � n = 208 patients n = 208 patients � � 1978 1978- -1995 1995 � � Operative Operative mortality mortality � � Long Long- -term term survival survival � � Impact Impact of of different different � surgical techniques techniques surgical Sabik et al. J Thorac Cardiovasc Surg 2002

Actuarial Survival Sabik et al. J Thorac Cardiovasc Surg 2002

Actuarial Survival Actuarial Survival Bental vs vs Resuspension Resuspension vs vs AVR AVR Bental Resuspension + graft (n=135) AVR + graft (n=26) Composite graft (n = 47) Sabik et al. J Thorac Cardiovasc Surg 2002

Freedom from Reoperations Reoperations Freedom from Composite graft vs vs Resuspension Resuspension Composite graft Sabik et al. JTCS 2002

Durability of of the the native native aortic aortic Durability valve after after resuspension resuspension valve Casselman et al Ann Thorac Surg 2000

Durability of of the the native native aortic aortic Durability valve after after resuspension resuspension valve � n = 246 patients n = 246 patients � (1976- -1999) 1999) (1976 � Operative Operative mortality mortality � � Long Long- -term term survival survival � � Impact Impact of of different different surgical surgical � techniques techniques � Fate Fate of of the the root root & valve & valve � Casselman et al Ann Thorac Surg 2000

Actuarial Survival Casselman et al Ann Thorac Surg 2000

Actuarial Freedom from Reoperation Casselman et al Ann Thorac Surg 2000

Echocardiographic follow-up of the aortic root after conservative surgery for Type A dissections Diametre (mm) (mm) N pts pts Diametre N < 35 37 < 35 37 36- -40 40 9 36 9 41- -45 45 7 41 7 46- -50 50 1 46 1 >50 2 >50 2 Casselman et al Ann Thorac Surg 2000

Aortic Valve Valve Preservation Preservation Aortic

The Aortic Valve and The Aortic Valve and The Aortic Root in The - PowerPoint PPT Presentation

The Aortic Valve and The Aortic Valve and The Aortic Root in The Aortic Root in Type A Aortic Dissections Type A Aortic Dissections Optimal Surgical Surgical Optimal Technique Technique Type A aortic aortic dissection dissection

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