Principles of Valve Sparing Procedure [Autosaved].pptx

Aortic valve sparing operations were developed to preserve the native aortic valve during surgery for aortic root aneurysm as well as surgery for ascending aortic aneurysms with associated aortic insufficiency.
There are basically two types of aortic valve sparing operations,
Remodeling of the aortic root (Yacoub Procedure)
Reimplantation of the aortic valve (David Procedure)
Remodeling of the aortic root is ideal for older patients with normal aortic annulus and primarily ascending aortic aneurysms
Reimplantation of the aortic valve should be employed in patients with inherited connective tissue disorders.
Remodeling of the aortic root has high failure incidence compared to reimplantation of the aortic valve

1. Principles of Valve Sparing Procedure And Results of Aortic Valve Surgery PRESENTED BY, D.E. NIRMAN KANNA, M.Sc., (PFT) Department of Clinical Perfusion, Narayana Hrudayalaya Institute of Medical Sciences, Bangalore, Karnataka.

2. VALVE SPARING PROCEDURE Aortic valve sparing operations were developed to preserve the native aortic valve during surgery for aortic root aneurysm as well as surgery for ascending aortic aneurysms with associated aortic insufficiency. There are basically two types of aortic valve sparing operations, R emodeling of the aortic root (Yacoub Procedure) R eimplantation of the aortic valve (David Procedure) Remodeling of the aortic root is ideal for older patients with normal aortic annulus and primarily ascending aortic aneurysms Reimplantation of the aortic valve should be employed in patients with inherited connective tissue disorders. Remodeling of the aortic root has high failure incidence compared to reimplantation of the aortic valve

3. DAVID PROCEDURE The  David procedure  was first performed by Dr. Tirone David on 1995 which involves r eimplantation the aortic valve with the aortic root. This technique was designed for patients with dilatation of the sinotubular junction, dilation of the sinuses of Valsalva and annulo -aortic ectasia. The advantage is that the annulus is stabilized, so patients with annuloaortic ectasia and connective tissue disorders may be less prone to late annular dilatation and recurrent AI.

4. STEP 1: Under the control of CPB Aortic cross clamp applied H eart is stopped and cooled by cardioplegia The aorta is transected just above the sinotubular junction of aorta The coronary ostia are removed along with coronary buttons of tissue. The remaining part of the ascending aorta is removed except for the aortic valve tissue.

5. STEP 2: Sutures will be placed under the valve and passed outside of the aortic annulus. A proper Dacron graft is selected and attached to the heart with the prepared sutures.

6. STEP 3: The valve is then carefully positioned within the graft to eliminate leaking. The valve tissue is completely attached to the graft with a horizontal mattress suture technique. Two small holes are created in the graft for reattachment of the coronary arteries. T he end of the graft is attached to the aortic arch A TEE was performed to ensure that the valve leaflets will open and close properly.

7. YACOUB PROCEDURE The  Yacoub procedure  was first performed by Dr. Yacoub on 1979 which involves remodeling the aortic valve, without reimplanting the aortic root. It’s indicated for people who are older and whose aneurysms aren’t caused based on a genetic syndrome .

8. A Dacron graft, sized to the internal aortic diameter, which is tailored to individually replace the resected sinuses. The commissural pillars are resuspended within the Dacron graft so that the leaves of the graft replace each coronary sinus, and so that they are stretched upwards slightly maintaining tension on the valve leaflets. The coronaries are reimplanted as buttons. YACOUB PROCEDURE

9. Choice of Technique

10. PROGNOSIS Postoperative elective mortality is approximately 1–2% (young patients) 10-year survival is 90–98% in David procedure, 10-year survival is just 75% in Yacoub procedure

11. Yacoub Procedure   vs David Procedure T he Yacoub procedure  ( remodeling) is aimed to the annular stabilization provided by the secure, straight proximal anastomosis, which naturally leaves unsupported residual aortic root tissues, and as well as the inter-leaflet and subcommisural tringles. The David Procedure ( reimplantation) approach functionally excludes all tissues at risk of future dilatation through their inclusion within the prosthetic graft.

12. Results of Aortic Valve Surgery Operative mortality of isolated AVR in patient <75 years is approximately equal to 1% Stroke (CVA) 71%, Re-exploration 71%, Complete heart block 71% Bio prosthesis failure 10–20% by 12 years and 30-35% by 20 years Mechanical valve reoperation 10–15% by 20 years.

13. EARLY MORTALITY Most early deaths are related to cardiogenic shock, CVA, hemorrhage. The higher mortality in patients undergoing bioprosthetic AVR is related to their higher preoperative comorbidity, including greater age. Euroscore weights the preoperative risk factors for early mortality

14. EUROSCORE

15. Overall survival (including hospital deaths) after AVR is approximately, 75% at 5 years 60% at 10 years 40% at 15 years 6 months after operation death rate steadies at around 2% Patients with bioprosthetic valves have significantly worse survival curves than patients with mechanical valves: as with early mortality, this reflects the greater age and comorbidity of this group. LATE MORTALITY

16. RISK FACTORS Higher age at operation (30-day mortality 1% age 40, 8% age 75) Female sex. Higher NYHA class, LV enlargement, grade of AR, angina, and AF. Number of previous AVRs, coexisting CAD, aneurysm, or LV structural abnormality. The operative myocardial ischemic time.

17. COMPLICATIONS Risk of re- exploration due to bleeding and tamponade 1% Postoperative MI 1% Deep sternal wound infection 1% Prolonged Mechanical ventilation 2% Organ Dysfunction 5% Complete Heart block 1% CVA 2% in isolated AVR and 3% Combined AVR + CABG Prosthetic endocarditis 10% but mortality is 60% Thromboembolism 1-2% per year Para prosthetic leak is very rare