Case 4 -

Aortic Valve Sparing Repair With Autologous Pericardial Leaflet Extension Michael C. Fishbein David Geffen School of Medicine at UCLA Los Angeles, CA

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Introduction: In 1988, Carlos Duran described a technique to repair the aortic valve using leaflet extension with pericardium previously treated with glutaraldehyde. The pericardium is then used to increase the height of the leaflets and commissures, thus, creating an additional area of coaptation. Case 4 - Slide 1 Click to view with ImageScope Click to view with a Web-Based Viewer Case 4 - Figure 1 - Diagram showing aortic view of bicuspid aortic valve after repair with pericardial extension. Case 4 - Figure 2 - Diagram showing side view of bicuspid aortic valve after repair with pericardial extension. Case 4 - Figure 3 - Kaplan-Meier curve showing freedom from reoperation after pericardial extension of aortic valve leaflets in children. Case 4 - Figure 4 - Kaplan-Meier curve showing freedom from reoperation after pericardial extension of aortic valve leaflets in adults. Case 4 - Figure 5 - Histologic sections showing junction of native valve (NV) and pericardial tissue valve (PV) after pericardial extension of aortic valve leaflets (2 left panels, H&E and trichrome x40). Third panel shows higher magnification of native valve tissue (x100) and 4th panel shows suture site (S) with pericardial tissue (P) covered by fibrosis (F)(x200). Case 4 - Figure 6 - Gross photograph of inflow and outflow surfaces of aortic valve after pericardial extension. Note white fibrous tissue and focal calcification (yellow) of leaflets. Case 4 - Figure 7 - Another gross example of inflow and outflow surfaces of aortic valve after pericardial extension. Case 4 - Figure 8 - Histologic section showing junction of native tissue (NT) and pericardial tissue (PT) with overlying fibrosis (F). Von Kossa stain confirms the presence of calcification (left x40, center x100, right x200). Case 4 - Figure 9 - Histologic sections of junction of native tissue (NT) and pericardial tissue (PT) with suture present (arrow) (H&E x100). Note connective tissue proliferation with myxoid change present. Patient and Methods: At UCLA, between January 1997 through September 2005, 128 patients underwent this reparative aortic valve surgery. Clinical, operative and outcome data were collected retrospectively. Our cohort was divided into two subgroups depend on patient's age: a pediatric group: 54/128 patients (42%) with a mean age of 8.4±5.4 years (range, 0 to 17 years) and adults: 74/128 patients (58%) with a mean age of 48.9±19.7 years (range, 19 to 85 years). 1 Pericardial patches were harvested from under the sternum and treated with glutaraldehyde for nine minutes. To shape the pericardial patches in the appropriate fashion, the width of each of these patches was 15% greater than the diameter of the aorta. The reduction in the pericardial leaflet free edge width from a purse stringing effect with a running polypropylene suture necessitates the 15% additional length. The height of the pericardial leaflet was measured to bring the extensions just below the sinotubular junction where all extended cusps may naturally coapt in the center of the aorta. The attachments were then extended up onto the wall of the aorta, thus creating commissures to provide coaptation of the leaflets approximately 4-5 mm from the edge of the valve commissures. The leaflets were then trimmed and attached at the proximal portion with through-and-through sutures through the aortic wall that were then passed through external pledgets and tied. The valve leaflets were assessed to assure coaptation. The incision was extended down to the annulus in order to slightly enlarge the ascending aorta to prevent narrowing due to the extra valve tissue. After coming off bypass, trans-esophageal echocardiogram was done to confirm aortic valve competency and evaluate ventricular function. Congenitally bicuspid valves were converted to a natural tri-leaflet configuration using autologous pericardial leaflet extensions. Results: In the pediatric group the mean follow-up was 35±30 months (range 0.1 to 93.1), pre-operative aortic regurgitation and stenosis grades by echocardiogram were 2.3±1.8 and 1.9±1.6 respectively, and the mean follow-up aortic regurgitation and stenosis grades were 0.8±0.5 (scale, 0-4) and 0.4±0.2, respectively. In the adult group, the mean follow-up was 32±29 months (range 0.1 to 93.1), the mean pre-operative aortic regurgitation and stenosis grades were: 1.5±1.3 and 1.2±0.9 respectively, and the follow-up mean aortic regurgitation and stenosis grades were 0.5±0.3 and 0.3±0.1, respectively. Reoperation for valve failure was performed for valvular regurgitation, stenosis, or both. In the pediatric group there were 6 total re-operations (6/54) in five patients; one was re-operated twice. From these 6 cases, 3 were re-repair and 3 had aortic valve replacement. In the pediatric group the mean interval between original repair and first re-operation was 4.3±2.5 years (range, 0.1 to 7.7 years). In the adults group were 5 re-operations (5/74). Of these 5 cases, 3 patients underwent aortic valve replacement and 2 re-repair. In the adults group the mean interval between original repair and re-operation was 3.5±3 yrs (range, 0.1 to 7 years). Reoperation provided the opportunity to review the pathologic changes in the valvular tisues involved in this type of repair. There were 3 basic changes observed in both the pericardial extensions (P) and native valvular tissue(N): fibrosis, calcification, and myxomatous degeneration. These were graded semiquantitatively from 0 to 3. The mean fibrosis score was: 1.9±1.5 in P, and 2.3±0.9 in N. Mean calcification was 1.3±0.7 in P, and 1.1 ±0.7 in N. Mean myxomatous change was 1.1 ±0.7 in P, and 1.8 ±0.9 in N. The native side of the leaflet has greater myxomatous changes than the pericardial side of the leaflet (p=0.01). There was no statistical difference in the degree of fibrosis (p=0.44) or in calcification (p=0.42). Discussion: Aortic valve repair is an evolving technique that can delay and sometimes avoid problems of valve replacement such as the biological constraints of growing children, pregnancy, tissue antigenicity, and bleeding and thromboembolic complications related to the need for anticoagulation therapy. The pericardium, previously treated with glutaraldehyde solution, provides resistance to retraction and degeneration, and preserves intrinsic tissue pliability. This technique demonstrates good long-term survival and low reoperation rates in both children and adults. This procedure can delay or obviate the need for aortic valve replacement, an especially attractive option in children. Aortic valve repair with autologous pericardial leaflet extension has low mortality and morbidity rates, as well as good long-term durability in both the pediatric and the adults groups. Selected References: Duran C., Gometza B., Kuma N, Gallo R, Bjonastad K. From aortic cusp extension to valve replacement with stentless pericardium. Ann Thorac Surg. 1995; 60:S428-32. Duran CMG, Gometza B, Kuma N. Aortic valve replacement with freehand autologous pericardium. J.Thorac Cardiovasc Surg. 1995; 110:511-6. Bozbuga N, Erentug V, Kirali K, Akinci E, Isik O, Yakut C. Midterm results of aortic valve repair with the pericardial cusp extension technique in rheumatic valve disease. Ann Thorac Surg. 2004; 77:1272-6. Odim J, Laks H, Allada V, Child J, Wilson s, Gjertson D. Results of aortic valve sparing and restoration with autologous pericardial leaflet extension in congenital heart disease. Ann Thorac Surg. 2005; 80:647-54. Halees Z, Shahid M, Sanei A, Sallehudin, Duran C. Up to 16 years follow-up of aortic reconstruction with pericardium: a stentless readily available cheap valve?. Eur J Cardiothorac Surg. 2005; 28: 200-2005.