AORTIC STENOSIS

&
AORTIC VALVE REPLACEMENT

Department CardioVascular Surgery

Medical University Plovdiv
AORTIC STENOSIS
 ETYOLOGY
• 1/ Congenital AS:

• Bicuspid (BAV)/ Unicuspid (UAV)

• 2/ Acquired AS:

• Calcific degeneration (Senile degeneration);

• Rheumatic AS;

• Other:Hypercholesterolaemia, Paget’s disease, Fabry’s

disease, Radiotherapy (RT)
AORTIC STENOSIS
AORTIC STENOSIS
CALCIFIC SENILE DEGENERATION
AS in BAV
CLINICAL PRESENTATION

• 1/Asymptomatic pts.

• 2/Symptomatic pts.:

• - HF ( NYHA class )

• - Syncope

• - Angina pectoris (ACS)

ECG
LV hypertrophy
IMAGING MODALITIES
• 1/ Echocardiography ( ТТЕ,ТЕЕ )

• - Most valuable and irreplaceable non-invasive modality for

assessment of: severity of AS, severity of calcification,LV
function,global kinetics,LV hypertrophy.

• 2/ Left Heart Catheterisation

• - Invasive/Interventional diagnostic modality, giving also

information about coronary artery circulation and eventual
CAD
 Echocardiography AS
Value MILD MODERATE SEVERE

Jet velocity
< 3.0 3.0-4.0 > 4.0
( m/s)

Mean gradient
< 25 25-40 > 40
( mmHg )

Valve area
> 1.5 1.0-1.5 < 1.0
( cm2 )

Valve area index

< 0.6
( cm2/m2 )
Guideline for AVR in AS
AHA / ACC/ ESC / ЕACTS
 Клас Препоръки
Дефиниция
препоръки за употреба

1. Пациенти със симптомна АС

препоръчително
2. Пациенти с тежка АС, преминаващи друга клапна
Клас I или байпас хирургия с индикации
3. Пациенти с тежка АС и ЛК дисфункция ( ФИ<50% )

Клас II
1. Пациенти с умерена АС, преминаващи байпас трябва да се
Клас IIa хирургия вземе предвид

1. Пациенти с тежка АС и абнормен тест с натоварване

2. Пациенти с тежка АС и голяма вероятност за бърза
прогресия на оплакванията
може да се вземе
Клас IIб 3. Пациенти с умерена АС по време на байпас хирургия предвид
ако аортната клапа е силно калцирана
4. Пациенти с тежка асимптомна АС и очаквана
оперативна смъртност < 1%

Клас III не се препоръчва

 ASYMPTOMATIC
AS

Annual risk for

Surgical risk 3-
SCD
6%
1%
 AS
EVOLUTION
• Good prognosis until onset of symptoms

• Annual risk for SCD < 1%

• Variable among patients

• Valve area decreases < 0.1 cm2 annually

• Risk for clinical onset of symptoms in 5 years = 50%

SURGICAL RISK FACTORS

• Chroniodyalisis (TRF)
• Age
• Shock
• Redo-Surgery
• COPD
• Urgency
• LVEF
 Conventional surgical
(S)AVR

• CPB
• Cannulation
• Cardioplegia
• Aortotomy
• Debridement
• Suture placement through aortic root
• Mechanical Valves
• Biological valves
• Suture/Closure of aortotomy
Mechanical vs. Biological

ANTICOAGULATION Y Y/N

LIFE UNLIMITED LIMITED

RE-OPERATION RISK Y/NO Y

BLEEDING RISK Y N

THROMBEMBOLIC
COMPLICATIONS Y Y/N

PROSTHETIC
Y Y
ENDOCARDITIS RISK
 Sorin
Carbomedics

Hancock II

Trifecta

Edwards Intuity
 MECHANICAL VALVES

(a) Starr-Edwards (b) Bjork-Shiley (c) St. Jude Medical

 Indications for Mechanical valves
• Patients < 70 ys.

• Exceptions< 70 г.

• Expected life in pts. > 15-20 г.

• Physically and professionally active pts.

• Exceptions

• Patients with permanent pacemaker devices

• Patients with A.Fib

Mechanical valves
Ball-in-cage
Starr-Edwards valve
MECHANICAL VALVES
Tilting disc
Bjork-Shiley valve
MECHANICAL VALVES
BILEAFLET
St. Jude Medical / Sorin Carbomedics
BIOLOGICAL VALVES

• Stented xenograft

• А. Bovine

• В.Porcine

• Stentless xenograft

• С.Porcine
 Indications for xenograft
Biological valves

• Patients > 70 ys.

• Exceptions

• Life expectancy < 10-15 ys.

• Patients with limited/compromised physical

activity

• Exceptions
BIOLOGICAL VALVES
Stented xenograft
BIOLOGICAL VALVES
Stentless xenograft
SHORT FUNCTIONAL LIFE IN BIOLOGICAL
VALVES

• А. WEAR & TEAR

• B. CALCIFICATION

• C. PANNUS

• D. ENDOCARDITIS

• E. THROMBOSIS
 1. CADAVERS

2. AFTER EXPLANTATION OF
THE DISEASED HEART OF
THE RECIPIENT HT PATIENT
WITH INTACT AORTIC ROOT,

HOMOGRAFT
 “The best valve is the own one"

PULMONARY AUTOGRAFT
ROSS PROCEDURE
Contegra
 ROSS PROCEDURE
INDICATIONS

• NEWBORNS: Aortic root hypolpasia

• Babies and infants: Progressive AS

• Adults < 40-50 ys.:

• -with contraindications to anticoagulation therapy;

• - with the aim to avoid any anticoagulation

• Diagnosis: BAV

• Operation conducted:
04/97

• - Ross procedure
( failed)

• - Homograft
( successful SAVR )

• Anticoagulation -
NONE
 LIFE EXPECTANCY +++ ++ ++ + ++

THROMBEMBOLIC
EVENTS +++ ++ ++ + +

BLEEDING
COMPLICATIONS +++ + + + +

RESISTENCE TO
INFECTION + + ++ +++ +++

COMPLEXITY OF THE
SURGICAL PROCEDURE + + ++ ++ ++++
 OZAKI Procedure
Aortic Valve Neo-Cuspidization
• Ozaki AVNeo - autologous pericardium

• - young fertile female patients of childbearing age;

• -contraindications to any anticoagulation therapy;

• -narrow aortic root;

• -infants and children;

• - bicuspid/unicuspid AV;

• - Chroniodyalisis patients
 • Left-sided thoracotomy

• no CPB

• In patients with high risk

for SAVR

• Previous open heart

surgery ( or multiple re-
entries )

• “Porcelain aorta”

APICO-AORTIC CONDUIT
 TAVI / TAVR
( Transcatheter Aortic Valve Implantation)
 Core Valve

Symetis Acurate

Lotus valve

Sapien XT
 TAVR
Indications
• Symptomatic patients with severely degenerated senile TRICUSPID aortic
valve

• Valve area < 1 cm2

• High-operative risk patients

• Patients with co-morbidities

• “Porcelain aorta”

• Patients with previous open heart surgery ( patent

bypass grafts and severe mediastinal adhesions )

• Valve-in-Valve ( degenerated biological aortic valves)

• Patients after Radiotherapy

Porcelain aorta
TYPES OF TAVI DEVICES

SELF-EXPANDABLE
А. Medtronic Core Valve
B. Medtronic Evolute R
BALLOON-EXPANDABLE
C. Edwards Sapien XT
D. Edwards Sapien 3
TRANS-APICAL TAVR
• Hybrid OR

• Left-sided
anterolateral
mini-thoracotomy

• no CPB

• Direct Fluoroscopy

• ТЕЕ guidance
HYBRID OR
What would Future
offer???
3D-BIOPRINTED VALVES
Under study and development