2. INTRODUCTION
Although, experience with aortic valve repair is
still less extensive than that of mitral valve,
many problems with prosthetic valves making
the decision to repair the aortic valve is
attractive.
3. Why aortic valve repair is
? attractive
Better haemodynamics.
Normal growth.
Problems with valve replacement:
…… Anticoagulation,
…… Small size,
…… Durability,
…… Infection,
…… Special problem:
4. Special problems
Large number of patients with rheumatic pathology
Late referral of cases ( VSD with aortic valve
prolapse)
In available substitutes (Ross procedure)
Clinical situations:
- Children
- Females in the child bearing period
5. Problems with aortic valve repair
Feasibility
- Small coapting surface
- Absence of supporting apparatus
Durability
Experience
Time
Early failure
6. Aim of the work
The choice of repair in our patients initiated
when the decision to replace the valve was
critical; children and young adults (especially
females).
We undertook this study to look at our early
experience with aortic valve repair as a pilot
study aiming at future expanding the number
and extending the follow up period.
7. Patients and methods
From August 2010 through February 2012, 10 patients with
severe aortic incompetence of two pathologic categories
underwent aortic valve repair ;
Group A: 6 patients with rheumatic aortic valve
incompetence (+/- mild AS) 4 of them combined with
mitral valve disease scheduled for mitral valve repair.
Group B: 4 patients with subaortic VSD and aortic
incompetence due to prolapse of right coronary cusp into the
VSD.
-
8. clINIcAl dAtA
G.A
G.B
RH. AI AI +VSD
Mean Age 18.8 9.7
((year
Female/male
4/2 3/1
NYHA III : 4 III : 3
II : 2 II : 1
Grade AI IV : 4 IV : 2
III : 2 III : 2
9. Exclusion criteria
Grade I AI.
Concomitant mitral valve replacement.
Ejection fraction less than 40%.
10. Pre and intraoperative
assessment
The echo images should be correlated with the IO
examination of the aortic root and valve.
A- Anatomy:
1- All components of the aortic root ;
•Cusps: number , thickness, free margins, excursion ,lines
of coaptation,
•Annulus: dilatation, calcification ,
•Sinuses: symmetric or asymmetric enlargement,
•Sinotubular junction and ascending aorta.
11. Pre and intraoperative
assessment
2- Geometry of the aortic root
The length of the base is
approximately 1.5 times
the length of the free margin.
The diameter of the aortic
annulus is 10/9 the diameter
of the STJ in young persons.
12. Pre and intraoperative
assessment
B- Haemodynamics:
Grade and mechanism of AI.
Cardiac function and dimensions.
Tools:
TTE: preop. and for follow up.
TEE: before and after bypass .
IO examination.
13.
14. Operative procedure
o Median sternotomy,
o Aortic-bicaval cannulation (single venous)
o Moderate hypothermia (28c),
o Cold blood antegrade ostial cardioplegia,
o Nearly circular aortotomy, suspention of the root
symmetrically in anticipation of repair.
15.
16. Operative procedure
;G.A: Rheumatic AI
Aortic valve repair Single aortic valve
.comb repair
with mitral repair
4 2
Aortic valve repair was attempted only if the mitral
valve repair was appealing satisfactory
20. Operative procedure
;G.B: AI+ VSD
VSD was inspected firstly trans aortic --
Trans atrial closure Trans aortic closure
With synthetic patch with direct suture
3 1
24. Assessment of Repair
(1) the cusps were visually inspected, and
aligned with each other to observe for
redundant or retracted tissues
(2) Saline can be injected into the aortic root
after closure of aortotomy and noticing the
filling af aortic root.
25. Assessment of Repair
(3) Heart is deaired , cross clamp is removed
and LV is noticed.
(4) TEE is the most important tool for
assessment of repair after weaning from
cardiopulmonary bypass. No more than mild
AI or PG more than 20 mmHg was accepted
with reasonable hemodynamics.
26.
27.
28.
29. RESULTS
Mean x Mean CPB Mean mech.
clamp ((minutes Ventilation
((minutes ((hours
G.A. 1; RH 90.2 112.7 14.8
.AI+MV rep
;G.A. 2 52.4 66 12.4
RH.AI
G.B; 72.5 89.7 11.7
AI+VSD
30. RESULTS
:Predischarge echocardiography
Grade of AI Mean Grade Max. PG
of AI ((mmhg
G.A; Cases : I 4 1 13
RH.AI 1Case : II
Case: 0 1
G.B; Cases: I 4 1 8
AI+VSD
31. RESULTS
( Follow up echocardiography: 6 -8 ms (8 cases
Progression of Mean Grade Max. PG
Grade of AI of AI ((mmhg
G.A; Cases : no 3 1.33 15
RH.AI 1Case : I II
G.B; Cases: no 3 1.25 6
AI+VSD Case: I II 1
32. RESULTS
There were no in hospital mortality or during the
follow up period.
There were no valve related complications.
All patients are in NYHA class I during the follow up.
33. Discussion
The well known advantages of valve repair and The
encouraging results of valvuloplasty in the MV have
influenced a resurgence of AV reconstruction.
However, aortic valve repair is technically more
demanding and still carries a high failure rate
because of the complex mechanism of the valve and
difficult assessment of the repair before coming off
bypass.
34. Discussion
So, the decision to repair an aortic valve is
made by weighting the risk of repair failure
versus its benefits.
Proper patient selection on the basis of
anatomy( depends mainly on the cusps) and
pathology (mostly it is exclusive to AI) and
the routine use of TEE are essential to avoid
an immediate unsuccessful repair.
35. Discussion
Aortic valve repair has generally been preferred for
patients with AI associated with VSD, aortic
dissection, or annuloaortic ectasia. Repair for cusp
prolapse with VSD is known to give good results
before 7 years of age before the severity increases
(Rathore 2006).
The mean age in this set of patients in our study was
9.7 years due to late referral and the short term
results as regarding the degree of AI and clinical
status were accepted for us.
36. Discussion
Experience with aortic valve repair in patients with
rheumatic heart disease is still limited despite some
reports about good results and increased follow up
periods. Ex. Freedom from development of moderate or
severe aortic valve disease of 82.5% ± 6.3% at a median of
103 months and 52.5% ± 16.9% at 160 months of follow-up
(Sachin, et al., 2005).
The mean age in this set of patients in our study was 18.8
years and the short term results as regarding the degree
of AI and clinical status were accepted for us.
37. Limitations
This study has the following limitations:
1) There is a learning curve and cases with
rheumatic pathology were selected.
2) The number of patients is still small.
3) The follow up period is still short.
So, it is planned to expand the study to larger number
of patients and to extend the follow up period.
38. Conclusion
Aortic valve repair in children with aortic
incompetence associated with VSD and
in selected cases with rheumatic aortic
valve pathology is feasible and yields
encouraging short-term results.
