Aortic Valve Repair

Question 1

Predictors of successful aortic valve repair (reimplantation technique)

Answer 1

thin cusps
mobile cusps
smooth free margins

Question 2

What are the different David operations

Answer 2

David I cylindrical tube graft
David II –this is the same as Yacoub–Scalloped graft
David III scalloped graft with external reduction annuloplasty
David IV Larger graft plicated at sinotubular junction

There is a stanford modficiation…I think it’s a larger distal graft (larger in proximal to recreate sinus)

There is a graft prostheses with fabricated sinus (Valsalva)

Question 3

What are the 4 components of the aortic root

Answer 3

Aorto-ventricular junction/aortic annulus
aortic cusps
aortic sinuses
sinotubular junction

Question 4

What is the size difference of the aortic cusps

Answer 4

Noncoronary cusp is usually larger then the right and left

The left is usually the smallest of the 3

Question 5

What are ways to determine the diameter of the dacron graft needed for aortic valve reimplantation

Answer 5

1. Same size as the STJ measured on echo
2. Using a stentless valve sizing device
3. Use a Hegar dilator or any true size valve sizer; for a reimplantationr you add 4 or 5 mm to this number
4. The height of each aortic valve cusp, take the average and then multiple by two
   Choosing a graft that is 15% greater then the average distance between commisural posts
5. Horizontal line from top of the non-coronary/left coronary commissure and another line that connects the nadir of the non-coronary and left-coronary cusps. The distance between these these two lines is the height.

Question 6

What is a repair-oriented functional classification of aortic insufficiency

Answer 6

Type 1: normal cusp motion with functional aortic annulus dilation or cusp perforation
Type 2: Cusp Prolapse
Type 3: Cusp restriction

Question 7

List techniques for leaflet/cusp repair

Answer 7

cusp extension
plication of the area of the nodule of Aranti
closure of stress fenestrations
in BAV you can shorten the elongated cusp narrow the sub-commissural triangles

Question 8

List as many aortic valve repair techniques as possible

Answer 8

STJ remodeling
Subcommissural annuloplasty 
plication 
triangular resection 
free margin resuspension 
shaving/decalcification 
autologous bovine pericardium  
ascending aortc graft implantation

Question 9

List other groups results for aortic valve repair

Answer 9

Munir Boodwani et al (El Khoury) JTCS 2009;137:286-94

Freedom from aortic valve re-operation at 5 and 8 year were 92 and 91 (n= 214 pts)
Freedom from AI of 2+ at 5 and 8 years was 88 and 79%

1 pt with aortic valve endocarditis
4 strokes

Question 10

What is long term results of aortic root repair using the reimplantation technique

Answer 10

David TE 2012 JTCS

Mostly tricuspid (only 11% bicsupid)   
Survival at 5,10 and 15 was 95%, 93% and 93%

Freedom from re-operation
5, 10 , and 15 was 99%, 97% and 97%

Freedom from moderate or severe AI
5, 10, and 15 was 98%, 92% and 89%

Question 11

List genetics of Marfan

Answer 11

Autosomial dominant (reduced penetrace) 
Chromosome 15
mutatations in Fibrillin-1 (FBN) 
Excessive TGF-beta 
Ongoing destruction of the elastic and collagen

Question 12

What is Loez-Dietz syndrome

What is recommended size to replace asending aorta

Answer 12

Triad of hypertelorism
Cleft palate
genrealized arterial tortuisity with aneursym/dissection
TGF-beta (1 and 2) receptors)

4.2 cm is recommended size for prophalytic replacement

Question 13

How is diagnosis of ED-syndrome confirmed

Answer 13

biochemical assays showing qualitative and quantitative abnormalities of type III collagen

Suspect in any young person with arterial or visceral rupture or colon perforation

Question 14

Ehlers-Danlos Syndrome

Answer 14

rare autosmial dominant inherited disorder of the connective tissue from mutation of COL3A1 gene encoding type III collagen

Question 15

List natural history of loeys Dietz syndrome

Answer 15

Mean age of death of 26 yo

Question 16

List Natural Ehrlos-Danlos

Answer 16

Median survival of 48 yo

Cause of death is arterial rupture or dissection

Question 17

List differences between re-implantation and remodelling procedures

Answer 17

Reimplantation: the valve is reimplanted inside of the Dacron graft. The VA junction is stabilized by the Dacron tube.
Remodelling: the Dacron graft is scalloped and the valve is anastomoses to the graft. VA junction is not stabilized but flow is more physiologic

Question 18

What patient is ideal for aortic valve remodelling

Answer 18

No connective tissue disorder

Question 19

What are potential reasons for failure of aortic valve repair techniques

Answer 19

Inadequate coaptation height (<4mm)
Inadequate effective height (<9mm)
Presence of more than 1+ AI at the end of the procedure
Coaptation line too low in the graft
Preoperative AV junction more than 28 mm
Use of pericardial patch

Question 20

What is aortic valve repair classification

Answer 20

Type 1 Normal,leaflet motion
    A dil STJ
    B dil STJ and sinus
    C dil AVJ
    D perforation

Type 2 excess motion
Type 3 restriction

Best result after repair with type 1 and 2

Question 21

What information from TEE is required for Aortic valve repair

Answer 21

Number of Cusps
Thickness
appearance of free margins
excursion of each cusp
lines of coaptation of the aortic cusps
direction and size of the regurgitant jet
morphology of annulus, sinuses, STJ, and ascending aorta
Mechanism of AI