| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
J Thorac Cardiovasc Surg 2009;137:293-294
© 2009 The American Association for Thoracic Surgery
Invited Commentary |
Dr El Khoury, I congratulate you on an outstanding study and especially for your great efforts to promote aortic valve reconstruction, which is an appealing operation improving in results and techniques. Nevertheless, some results are suboptimal, and a lot of questions are open. You could nicely demonstrate that a seemingly simple repair-oriented classification system of AI supports the understanding of functional anatomy for standardization of reconstructive techniques. Also, your classification system, which combines surgery and anatomy, is useful to direct the choice of the operative method in general. More details, however, are important for decision making and the success of the operation. Briefly, precise definitions are desirable. Thus my first question is as follows. Your classification type I refers to dilatation of different levels of the root. What exactly do you mean by dilatation? You measured the diameters by echocardiography and intraoperatively, but what are your threshold values for diameters to call it dilatation, which is important for decision making?
Dr El Khoury. Thank you, Dr Sievers. The concept of functional aortic annular dilatation is helpful in determining the surgical techniques for this strategy. When we have functional aortic annular dilatation, we have aortic regurgitation; conversely, when we have aortic regurgitation, I believe we have some kind of functional aortic annular dilatation. Saying that, type Ia and type Ib are the classic aneurysmal dilatation of the aneurysmal descending aorta and the root, and we use the standard measurement as the indication for surgery. If we look at types Ic, Id, and even II, I support that there is functional aortic annular dilatation. We have to look at it as a mismatch between the quantity of leaflet present and the aortic orifice. So the idea is that when we have this mismatch between the quantity of tissue and the orifice, we have two ways to restore the match: either extend the leaflet with cusp extension, or reduce the functional aortic annulus. So for types Ia and Ib, it is the classic definition of aneurysm, but for types Ic, Id, and II, it is really the idea that when we have regurgitation, we have some kind of mismatch, and the idea of valve repair is to restore the match between the leaflet and the aortic orifice.
Dr Sievers. Second, when you assess the aortic valve for the mechanisms of AI, especially in type II insufficiency, do you use special tricks or instruments or sutures to imitate the shape of the root at diastolic pressure to decide which of the various techniques to apply?
Dr El Khoury. After the standard transverse aortotomy, I use a systematic approach. After the transverse aortotomy 1 cm above the STJ, I put three-sutures at the commissures, and I put traction on those three sutures. First, I inspect, and sometimes in the first inspection I can see which leaflet is prolapsing or if the three leaflets are at the same level. So, the first step is inspection. If I am not happy with the inspection, I have to know the appropriate level of the leaflet. If one looks at the normal aortic valve in an echocardiogram, if this is the STJ and this is the leaflet, if one looks at the echocardiogram, the level of the free margin is really at the mid height of the commissure or mid height of the sinus of Valsalva. So when I open the aorta, I put traction on the three commissures, and with the forceps at the middle of the Arantius node, I can push down the leaflet and see at which level each leaflet goes down and whether the three leaflets are at the same level. This is one way I use.
The second way I use is to put a 7-0 or 8-0 suture at the middle of the cusps and pull up. Usually the free margins are running parallel when the leaflets are normal, but if one looks on the prolapsing one, the free margin is not parallel. So the nonparallel free margin is the prolapsing one. I don't use any instruments.
Dr Sievers. The last question is as follows. I had to reoperate on some of our 430 reconstructed aortic valves for subcommissural annuloplasty failure, but only in patients with a bicuspid valve, not a tricuspid. So at least in my hands, there seems to be a difference concerning subcommissural annuloplasty and valve etiology. Do you think it makes sense to consider valve etiology in your repair-oriented classification system?
Dr El Khoury. We were taught by Professor Carpentier that cardiac surgeons usually don't care about etiology. We have to restore the function of the valve.
The bicuspid aortic valve in our classification is type II or type I. So it can be type Ia, Ib, or whatever. This is mainly Ia and Ib, and I think that it is Ic in the pediatric population. I am aware of your classification for bicuspid aortic valve. And we had a discussion in New York at the Aortic Symposium about the indication for surgery and the size of the aortic root and bicuspid, tricuspid, whatever. But I think we have missed one thing, that is the perioperative assessment and examination of the quality of the aortic wall. Mainly in the bicuspid aortic valve, even if the aortic root is normal, we can find that the leaflet at the insertion to the aortic wall is too transparent, too thin, and we can see even the muscle. So in those cases, I think we have to be more aggressive and not do subcommissural annuloplasty but go to the valve-sparing operation, the David operation or whatever. I think that diameter is not enough for the indication to replace the ascending aorta with a bicuspid aortic valve. We also have to look the quality of the tissue.
Dr Christopher M. Feindel (Toronto, Ontario, Canada). First, I congratulate you for trying to put some methodology and organization to what still seems to be an eyeballing technique. I think this is a great help.
I do have a question about type III and your efforts to decalcify valves. I must say, years ago I learned painfully that this was a lousy operation, and we ended up reoperating on every one of those patients.
Dr El Khoury. With regard to type III, we have two kinds. We have type III associated with bicuspid aortic valve when we have the raphe, so we can resect the raphe. This is one thing. Type III with a tricuspid aortic valve, however, in our experience is different. I repaired everything some years ago, but now I really limit in type III when I see, for instance, coronary artery surgery and moderate aortic regurgitation and moderate stenosis. The valve really doesn't move very well, so in those patients we replace or repair the valve. In many, many of those patients, really almost all the patients, we go and do some shaving, clean the valve, and add subcommissural annuloplasty.
Dr Feindel. And do you not think that those patients come back faster for reoperation but now with, in many cases, working bypass grafts?
Dr El Khoury. I am not sure that we are accelerating the process. You can do nothing, and maybe the patient will come back for repair the valve. I am not sure that we are really accelerating the process of calcification by only shaving.
Dr Feindel. Our experience has been different. We have found that we ended up reoperating on those patients 3, 4, 5 years down the road, whereas with a bioprosthetic valve, the patient has at least 10, 12, or 15 years.
Dr El Khoury. It would be useful to conduct a randomized study.
| ||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
