7(a) Preoperative angiogram without opacification (a) Preoperative angiogram without opacification. The heavily calcified aortic root and aortic cusps are seen (triangles). (b) Preoperative aortogram. The stenotic sinotubular ridge (17 mm in diameter; arrow) and the stenotic aortic annulus (17 mm) are seen. The second degree of aortic regurgitation is also observed. (c, d) Postoperative aortograms: The enlar-ged sinotubular ridge and aortic annulus asso-ciated with the inserted 19-mm CarboMedics valve are seen. The pros-thesis placed almost pa-rallel to the original aor-tic annulus shows a nor-mal motion with minimal central regurgitation
8Size of Prosthesis for AVR a) 19 mm · Prohibitively high LV/Ao gradient · Enlarge the aortic root or perform Ross procedure instead b) 21 mm · Adequate size if BSA M2 and patient is sedentary · If BSA greater than 1.7 M2 = enlarge the aortic root (10 year survival 80% vs 60%) c) 23 mm or larger · Acceptable LV/Ao gradient in all patients
9Risk Factors for Survival after AVR · Advanced age · Functional status (NHYA class) · Depressed LV function (aortic incompetence) · Coronary artery disease · Presence of endocarditis · Aneurysm of ascending aorta · Mismatch of prosthesis and body size
10Survival After AVR a) Early (hospital) death - 3-6% b) Time-related survival · 5 years - 75% · 10 years - 60% · 15 years - 40% c) Mode of death · Early due to CHF, hemorrhage, infection, CVA · Sudden - 20% · Device related - 20%
12In patients with significant aortic valve disease conventional (stented) aortic valve replacement is the standard approachImplantation of a stentless aortic valve (SAV) is technically more demandingHowever SAV may offer better hemodynamic function and improved left ventricular reverse remodeling
14Mean gradient at rest and maximal exercise Peak gradient at rest and maximal exercise. The change in gradient from rest to exercise is compared with the change in the normal group. *p < versus NOR. (NOR = normal native aortic valves; TSPV = Toronto stentless porcine valve; FR = Medtronic Freestyle; SOR = Sorin Bicarbon; SJM = St. Jude Medical.)S.Silberman: Exercise hemodynamics of aortic prostheses: comparison between stentless bioprostheses and mechanical valves Ann. Thorac. Surg. 2001;72:Mean gradient at rest and maximal exercise
15LVH is an independent cardiac risk factor "An increase in left ventricular mass predicts a higher incidence of clinical events, including death, attributable to cardiovascular disease. "Levy et al, N Engl J Med 1990;322:1561
16LV mass - index [g/m2]Indexed ventricular mass regression in both groups over time. (CE = Carpentier-Edwards stented valve; LVMI = left ventricular mass index; SPV = Toronto stentless porcine valve.).G. Cohen et al. Are stentless valves hemodynamically superior to stented valves? A prospective randomized trial Ann. Thorac. Surg. 2002;73:
17Actuarial survival between stented and stentless groups Actuarial freedom from reoperations between the stented and stentless groups.Actuarial survival between stented and stentless groupsM. Vrandecic et al. Retrospective clinical analysis of stented vs. stentless porcine aortic bioprosthesesEur. J. Cardiothorac. Surg. 2000;18:46-53.
20Operative mortality for aortic Homograft insertion
21Left ventricular mass index (LVMI) preoperatively (PREOP) and 8 months after (POSTOP) aortic valve replacement. The homograft and stentless valves expressed the maximum LVMI reduction. This is evident in all cases (A) and in patients with a preoperative LVMI of 180 g/m2 or less (B). In patients with a preoperative LVMI of 180 g/m2 or more (C) the homograft treatment achieved the best results. (I = intact; H = homografts; T = Toronto; F = freestyle; C = controls).Ann. Thorac. Surg. 1999;67: Left ventricular mass reduction after aortic valve replacement: homografts, stentless and stented valves Daniele Maselli
22Long-term survival after Homograft aortic valve replacement
23Cumulative survival rates after homovital homograft aortic valve replacement with root replacement, freehand two-suture line technique (subcoronary), or either technique with associated procedures.
24Cumulative survival rates of all patients undergoing homovital homograft aortic valve replacement, including early death. Numbers above the abscissa indicate patients at risk at 1, 5, and 10 years. Five- and 10-year survival rates plus or minus SEM are given
25A depiction of the interrelationships between the overlapping mechanisms of allograft valve failure influenced by known risk factors—(younger) recipient age, (older) donor age, (larger) aortic root diameter, insertion technique, and valve preservation technique. Although compiled from a series of cryopreserved and antibiotic sterilized valves, these risk factors may play a role in failure of either type of valve.
26Pulmonary Autograft (Ross Procedure- 1967) AdvantagesViable tissue, excellent hemodynamicsNear 0% thromboembolism, growth potentialNon-antigenicPulmonary valve equal in strength as aortic valveDisadvantageCreating 2-way valve pathology from single valve diseaseResultsFreedom from re-operation 81% at 8 years5-10% annular dilatation and regurgitationPulmonary homograft deteriorationTechniqueRoot replacement preferredTailoring of aortic/pulmonary size mismatchBolstering ring with Dacron stripLong-term follow-up still accruing
28Operative mortality for aortic valve replacement with pulmonary autograft
29Reparative aortic valve surgery. Reproduced from Duran and colleagues
30The Marfan syndromeThe most common genetically determined disorder affecting adults (1/10,000 births).It is associated with a defect on chromosome 15 that affects fibrillin synthesis. (Fibrillin and elastin represent the major components of the elastic fiber system).Histopathologically, the aorta demonstrates cystic medial degeneration:disruption of elastic fibersfibrosis of the media.The abnormal elastic tissue predisposes patients toaortic root dilation with or without associated aortic regurgitation (75-85%),significant mitral regurgitation (30%).In addition to cardiovascular disease, the Marfan syndrome is associated with ocular, pulmonary, musculoskeletal, and central nervous system abnormalities
31Natural History The average age of death is approximately 32 years. The majority of deaths are cardiovascular:related to aortic root dilation in 60–80%:Aortic rupturedissection,heart failure from valvular disease (Aortic and mitral)The mean rate of aortic root dilation is 1.9 mm/year (however, individual rates of aortic expansion are highly variable and unpredictable).Acute dissection may occur in ascending aortas that are not greatly dilated.The risk of aortic root complications may be higher in individuals with a family history of aortic dissection.
33Surgical Procedures “Valve-Sparing Operation” (M. Yacoub – T. David) COMPOSITE GRAFTReplacement of the ascending aorta and aortic valve with a composite graft containing a mechanical valve and a collagen- or gelatin-impregnated Dacron graft and reimplan-tation of the coronary arteries .AORTIC HOMOGRAFTAortic root allografts can be used to replace the aortic valve, the aortic sinuses, and the ascending aorta.PULMONARY AUTOGRAFTSPulmonary root autografts are also used to replace the aortic root and adjacent ascending aorta.“Valve-Sparing Operation” (M. Yacoub – T. David)In cases of annuloaortic ectasia and aortic leaflets are normal, annuloplasty can be performed by suturing an appropriately sized Dacron tube graft circumferentially to the tissue immediately beneath the aortic annulus. The dilated aortic sinuses are excised, the aortic valve is resuspended within the tube graft, and the coronary arteries are reimplanted. The advantages: the avoidance of anticoagulation and lower risk of thromboembolism and endocarditis
34DILATAZIONE DELL’AORTA ASCENDENTE definizione della patologia ⇧Diametro > 1,5 x Diametro predettoDiametro predettoEtàSuperficie corporeaRilevanza della comorbiditàConnettivopatieAorta bicuspide
36Dilatazione aorta ascendente indicazioni al trattamento Criteri di indicazioneCut-off standard50 mm (no aorta bicuspide, no connettivopatie)Velocità di accrescimento della dilatazioneNecessità di almeno 2 misurazioni distanti≥ 2mm/annoRischio personalizzatoBSA, età, comorbidità, familiaritàR= eC(MD-PD)/MD
37Indicazioni Chirurgiche specifiche nella sindrome di Marfan Diametro della radice aortica ≥ 45mmAnamnesi familiare positiva per dissezione e diametro della radice ≥ 40 mmRischio personalizzato
39la chirurgia della radice aortica La terapia chirurgica è il solo trattamento definitivo della patologia della radice aorticala chirurgia della radice aortica(sostituzione valvolare e/o dell’aorta ascendente) rappresenta circa il 15% degli interventi cardiochirurgici dell’adulto
40Intervento di BentallSostituzione della valvola aortica e dell’aorta ascendente con reimpianto delle coronarie
43Crescente impulso allo sviluppo di tecniche conservative: Assenza di un sostituto “ideale” che possa riprodurre la “perfezione” della radice aortica nativa normaleLa scelta della strategia chirurgica ha l’obiettivo di offrire al paziente i migliori vantaggi clinici e funzionaliCrescente impulso allo sviluppo di tecniche conservative:“Sparing Technique”
44“Sparing technique” anche in presenza di alterazione valvolare: PRESERVARE la“Radice Aortica” come entitàanatomo-funzionale“Sparing technique” anche in presenza di alterazione valvolare:EndocarditeValvola bicuspide - Prolasso di una o più cuspidi
56The “pseudosinus model remodelling” SPARING TECHNIQUEThe “pseudosinus model remodelling”La dilatazione della radice compresi i seni viene escissa. Impianto di protesi “scalloped” che permette una dinamica tipo seni di Valsalva
68durata e sopravvivenza L’approccio conservativo “sparing technique” nella patologia della radice aortica e/o aorta ascendente rappresenta un’alternativasicura ed efficacealle tecniche tradizionalidimostrando buoni risultati in termini didurata e sopravvivenzaa distanza