1. Aortic root surgery Decision making
Kriengchai Prasongsukarn, 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 commissurotomy หลังทำ3 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 ms.), LVEDD 65 mm, LV enlargement, Aortic annulus 2.75 cm., Pulmonic valve 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 cusp and 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 female 59 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 %
female - 25%
ECG: sinus - 92%
AF %
Previous AVR - 10%

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

18. AVR - Hancock II Bioprosthesis
Infective endocarditis: Active - 24 pts
Healed - 11 pts
Coronary artery disease: pts (44%)
Ascending aortic aneurysm: 73 pts (11%)
Left ventricular EF: >40% pts (64%)
<40% pts (21%)
N.A 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 (3.2%)
Sternal infection - 4 (0.6%)
Early endocarditis - 2 (0.3%)

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

22. Hancock II: AVR Survival

23. Hancock II: AVR Free From Structural Valve Dysfunction

24. Hancock II: AVR Free From Structural Valve Dysfunction

25. Hancock II: AVR Free From Reoperation

26. AVR: Hancock II Bioprosthesis Summary 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 /-12
NYHA class IV %
Coronary artery disease %
Banbury et al - Ann Thorac Surg – 2001;72:753

28. AVR with CE Perimount Freedom 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 years
Hancock II
David et al ± %
Rizolli et al ± %
CE Perimount
Banbury et al ± %
Neville et al ± % (12yr)
Frater et al ± % (14yr)
SJM Biocor %
CE porcine %

31. AV Bioprostheses Freedom 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 Homograft Freedom from Reoperation
10 year = 87%
15 year = 76%
Pts’ mean age = 47 yrs
Pts at risk
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 Homograft Freedom from Reoperation & Failure
10-year % %
20-year % %
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 Freestyle Freedom from Reoperation
10 yr = 92%
Pts at risk
Bach et al. – Ann Thorac Surg 2005;80:480

41. AVR with Medtronic Freestyle Freedom 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
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 year
Freedom from death % %
Freedom from reoperation % %
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
: 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 Endocarditis Experience 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%)

51. Surgery for Active Infective Endocarditis Experience at Toronto General Hospital
Operations performed
268 replacement/repair of one (212 patients) or two or more valves (56 patients)
NO aortic homograft used
150 reconstruction of annulus + valve replacement of one (88 patients) or two or more valves (62 patients)
18 aortic homograft used
Mechanical valves in 42%; tissue valves in 55%; valve repair alone in 3%

52. Surgery for Active Infective Endocarditis Experience at Toronto General Hospital
Operative mortality: 11.5% Predictors: Odds ratio Shock 5.2 Prosthetic valve 3.2 Preop renal failure 2.3 (Surgeon was a predictor of operative mortality in patients with prosthetic valve and/or abscess)

53. Surgery for Active Infective Endocarditis Survival
5 year = 74%
10 year = 63%
15 year = 45%
Pts at risk

54. Surgery for Active Infective Endocarditis Survival: Valve vs. Abscess
1 year year
Valve % %
Abscess 81% %

55. Surgery for Active Infective Endocarditis Freedom from Recurrent Endocarditis
5 year = 93%
10 year = 88%
15 year = 86%
Pts at risk

56. Surgery for Active Infective Endocarditis Freedom from Reoperation
5 year = 97%
10 year = 91%
15 year = 71%
Pts at risk

57. Surgery for Active Infective Endocarditis Conclusions
Continues to be associated with high operative mortality and morbidity, particularly in patients with aortic root abscess
Radical resection of all infected tissues is probably more important than the valve implanted as far as the chances of curing the endocarditis

58. Conclusions Homograft
AV homograft offers no advantage over xenograft valves in patients with aortic stenosis
AV homograft may be ideal for patients with infective endocarditis with paravalvular abscess but it is not a substitute for radical resection

59. Homograft aortic root replacement
More technically demanding (less rigid nature of tissue)
Recommended in age years
Study by McGiffin showed the unacceptably high incidence of valve failure over 15 years period
McGiffin/ Grinda / Lytle found improved freedom from recurrent endocarditis compared with prosthetic material

60. Pulmonary autograft

61. AVR with Pulmonary Autograft TGH Experience (1990-2003)
213 patients
66% men
Mean age: 34 years (16 – 63 years)
AV pathology:
82% - bicuspid/congenital
5% - prosthetic dysfunction
2% - rheumatic
10% - miscellaneous

62. AVR with Pulmonary Autograft
AV lesion: AS %
AI %
AS+AI %
Follow-up: 6.1±3.4 years; 100% complete
Annual echocardiographic studies
Annual visit to cardiologist and/or valve clinic

63. AVR with Pulmonary Autograft Operative Outcome
One operative death: AMI
2 late deaths: 1 accident, 1 suicide
11 patients had reoperations: (no death)
2 – false aneurysms (valve saved)
5 – aortic insufficiency (valve replaced)
2 – pulmonary homograft stenosis
2 – coronary artery bypass
17 patients developed moderate or severe AI
182 (85%) – free of any adverse event

64. AVR with Pulmonary Autograft Survival and Freedom from Any Reoperation
12-year:
Survival = 98%
Reop Free = 87%
Pts at risk

65. AVR with Pulmonary Autograft Freedom from Aortic Insufficiency
12 yr = 88±4%
3+ AI = 12 patients
4+ AI = 5 patients
13/17 due to dilation
Pts at risk

66. AVR with Pulmonary Autograft Predictors of Moderate or Severe AI
Incompetent bicuspid aortic valve
Odds ratio: 3.6
Mismatch between aortic and pulmonary annuli >4 mm
Odds ratio: 2.9
Incompetent bicuspid aortic valve + mismatch
Odds ratio: 8.5

67. AVR with Pulmonary Autograft Freedom from Moderate or Severe PI ± >40mmHg PS
12-yr = 86±4%
Age  34 years = 72%
Age > 34 years = 100%
Pts at risk

68. AVR with Pulmonary Autograft Predictors of Pulmonary Valve Homograft Dysfunction
Patients’ age (by 5 years reductions)
Odds ratio 1.6
10 year freedom from PV dysfunction:
<20 yr-old = 62%±8%
20-30 yr-old = 85%±5%
>30 yr-old = 95%±2%

70. Result

71. Factor for late AI Male Aortic/ pulmonic annular mismatch
Aortic annulus >= 27mm
Preoperative AI
Female, Aortic stenosis, annulus <27 mm got best outcome
Not recommended in bicuspid aortic valve, marfan syndrome, connective tissue disease

72. Ross Procedure Very demanding technically
80 % freedom from reoperation at 20 years
Promise for IE
David found dilatation of neoaortic valve in bicuspid aortic valve disease
Reserve for young patients who are not predisposed to aortic or pulmonary artery dilatation

73. Conclusions Pulmonary Autograft
AVR with pulmonary autograft is probably the ideal valve for young adults who are physically active and have aortic stenosis
Pulmonary autograft should be avoided in patients with mismatch between the aortic and pulmonary annuli by more than 4 mm and/or an incompetent bicuspid aortic valve

74. Composite valve graft
Used in abnormal aortic cusp and dilated aortic root
Results varied as the indication of surgery (aortic dissection less than aneurysm)
Mortality 5-10%
Freedom from TE93%
Freedom from endocarditis 90%
Freedom from reoperation 74%

75. CVG with tissue valve

77. Results of CVG Low operative MR (4-10%)
Excellent long term survival (10 year survival 60%)
Freedom from TE, Endocarditis and Reoperation is good

78. Aortic valve sparing
30 % of Aortic root replacement has normal aortic valve
Two technique: Remodeling (Yacoub)
Reimplantation (David)
(Less AI, good hemostasis, less reoperation, redo for AVR easier)

79. Aortic valve sparing
Indication are expanding to bicuspid aortic valve and type A dissection
Result (freedom from reoperation) is excellent

80. Remodeling (Yacoub technique)

81. Reimplantation (David technique)
MR 0.6%
15 year survival 87.8%
15yrFreedom from AI 79.2%

83. Aortic Root Replacement
Aortic Regurgitation
Congestive Heart Failure
Prominent Ascending Aortic Shadow
History
Physical Examination
Chest x-ray
Echocardiogram
CT/MRI A B
Aortic Root Pathology
Mild-moderate AI
Size<5.0 cm
Severe AI
Size > 5.0 cm
Medical therapy
And follow-up C
Aortic Root Replacement D
Age < 40
Age 40-60 F
Age > 60 G
Extensive or
Prosthetic Valve
Endocarditis
Acute Type A
Aortic Dissection E
Aorta not dilated
Aorta dilated
Ross Procedure
Aortic valve
diseased
Aortic valve
not diseased
Homograft Root H
Aortic valve
not diseased
Aortic valve
diseased
Aortic valve
not diseased
Aortic valve
diseased
Mechanical or
Tissue CVG
Homograft Root
Xenograft Root
Valve-Sparing
Root Replacement
Aortic valve
diseased
Aortic valve
not diseased I
Mechanical CVG
Xenograft Root
Valve-Sparing
Root Replacement
Valve-Sparing
Root Replacement
Mechaical or Tissue
CVG
Separate Valve-Graft
Valve-Sparing Root
Replacement
Tissue CVG
Xenograft Root
John S. Ikonomidis, Aortic root replacement, in cardiac surgery

85. Conclusion Type of surgery: depends on
Patient condition
Age, comorbidity, condition of native aortic valve, pulmonic valve, limitation of anticoagulant usage postop
Valve preference in each patient
Surgeon (experience, skillful)

86. 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

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

88. Case 2 Case ผู้หญิงไทย อายุ 22 ปี
DX severe AS (อายุ 19 ปี ) s/p AV commissurotomy หลังทำ3 months มีเหนื่อย
ประมาณ 1-2 เดือน หลังจากคลอดบุตรคนแรกผู้ป่วยเหนื่อยมากขึ้น ตรวจพบว่ามี severe AR, ผู้ป่วยมาปรึกษาแพทย์ว่าถ้าหลังจากการผ่าตัดแล้ว ผู้ป่วยยังอยากที่จะมีบุตรต่อ

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

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

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

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

93. 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 14x9.9 mm attached to left cusp involve to septum, pulmonic valve 24. mm

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

95. 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

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

97. Case 6 female 59 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

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