Intraoperative Transesophageal Intraoperative Transesophageal Echocardiographic Predictors of Echocardiographic Predictors of

Recurrent Aortic Regurgitation after Recurrent Aortic Regurgitation after Aortic Valve RepairAortic Valve Repair

le Polainle Polain JB, JB, PouleurPouleur AC, AC, Vancraeynest DVancraeynest D, , Pasquet APasquet A, , Gerber BGerber B, , Vandijck M, Noirhomme P, El Khoury G, Vandijck M, Noirhomme P, El Khoury G, Vanoverschelde Vanoverschelde JLJL

Cliniques Universitaires Saint Luc, Brussels, BelgiumCliniques Universitaires Saint Luc, Brussels, Belgium

Université Catholique de LouvainUniversité Catholique de Louvain

Aim of the studyAim of the study

The present study examines the The present study examines the intraoperativeintraoperative echocardiographicechocardiographic

featuresfeatures associated with associated with "late failure""late failure" of aortic valve repair.of aortic valve repair.

Method: Study populationMethod: Study population

From 12/From 12/1995 1995 to 06/to 06/20072007 186 186 consecutive patients (51 women, mean age: 54-Yrs) consecutive patients (51 women, mean age: 54-Yrs)

-- Aortic valve repair for significant AR Aortic valve repair for significant AR -- With comprehensive pre-, intra- and follow-up With comprehensive pre-, intra- and follow-up echocardiographyechocardiography

122 pts122 pts (group A, 53- Yrs) with no AR (group A, 53- Yrs) with no AR

23 pts23 pts (group B, 50- Yrs) with > grade 1 AR (group B, 50- Yrs) with > grade 1 AR

41 pts41 pts (group C, 63- Yrs) with recurrent severe (group C, 63- Yrs) with recurrent severe ARAR

Compared for immediate post-operative TEE Compared for immediate post-operative TEE measurements.measurements.

Analysis of the cause of recurrence (group B & C).Analysis of the cause of recurrence (group B & C).

Method: TEE analysisMethod: TEE analysis Pre-operative and immediate postoperative TEE :Pre-operative and immediate postoperative TEE :

120 degree -LAX120 degree -LAX AnnulusAnnulus

SinusesSinuses

ST junctionST junction

Tubular aortaTubular aorta Height of the sinusesHeight of the sinuses

Coaptation lengthCoaptation length

Symmetry of the coaptationSymmetry of the coaptation

Tips to annulusTips to annulus

Cusp’s belly to annulusCusp’s belly to annulus Eccentric JetEccentric Jet

Vena contracta wideVena contracta wide

Results (1): Follow-up:Results (1): Follow-up:

Mean Follow-up :Mean Follow-up : 24 24 monthsmonths41 41 pts had recurrent pts had recurrent severe ARsevere AR2323 needed a needed a REDOREDO

F-up TEEF-up TEE identified the cause of repair failure as identified the cause of repair failure as

Cusp prolapse: 26 pts Cusp prolapse: 26 pts

Restrictive cusp motion: 9 ptsRestrictive cusp motion: 9 pts

Rupture of a pericardial patch : 3 ptsRupture of a pericardial patch : 3 pts

Aortic dissection : 2 pts Aortic dissection : 2 pts

Endocarditis : 1 ptEndocarditis : 1 pt

Results (2): Pre-operative Results (2): Pre-operative characteristicscharacteristics

Before surgeryBefore surgery Group AGroup A

(n=112)(n=112)Group B Group B (n=23)(n=23)

Group CGroup C

(n=41)(n=41)P valueP value

Bicuspid (%)Bicuspid (%) 40 17 37 0.12

Marfan (%)Marfan (%) 0 9 15 <0.001

Restrictive AR (%)Restrictive AR (%) 13 43 46 <0.001

Annulus (mm)Annulus (mm) 25 ± 4 24 ± 4 26 ± 6 0.27

Sinus (mm)Sinus (mm) 40 ± 8 39 ± 9 41 ± 13 0.61

ST jct° (mm)ST jct° (mm) 35 ± 9 35 ± 9 34 ± 9 0.93

Tubular Ao (mm)Tubular Ao (mm) 42 ± 11 39 ± 8 37 ± 13 0.14

Results (3): immediate post-op TEE:Results (3): immediate post-op TEE:

After surgeryAfter surgery Group AGroup A

(n=112)(n=112)Group B Group B (n=23)(n=23)

Group CGroup C

(n=41)(n=41)P value P value

Coapt. Length Coapt. Length (mm)(mm)

6.6 ± 2.8 3.2 ± 1.4 2.2 ± 1.6 <0.00

1

Tips - annulus Tips - annulus (mm)(mm)

6.9 ± 4.3 3.0 ± 3.1 0.1 ± 4.2 <0.00

1

Cusp - annulus Cusp - annulus (mm)(mm)

-1.2 ± 2.8 -1.5 ± 3.2 - 3.9 ± 4.8 <0.00

1

Vena contracta Vena contracta (mm)(mm)

0.1 ± 1.1 2.4 ± 1.7 2.6 ± 1.4<0.00

1

Eccentric Jet (%)Eccentric Jet (%) 9 30 73<0.00

1

Annulus (mm)Annulus (mm) 21 ± 4 21 ± 4 26 ± 4<0.00

1

Sinus (mm)Sinus (mm) 29 ± 5 30 ± 5 31 ± 5 0.04

ST jct° (mm)ST jct° (mm) 26 ± 4 24 ± 4 27 ± 4 <0.01

Results (4):Results (4): Cox univariate analysis Cox univariate analysisPreoperative Preoperative Type 3 ARMarfan disease

PostoperativePostoperativeThe coaptation lengthThe degree of cusp billowingThe level of coaptation (relative to the annulus)The diameter of the aortic annulusThe diameter sino-tubular junctionThe presence of a residual ARThe severity of residual AR (vena contracta width)

Were found to correlates with AR failure

Results (4):Results (4): Cox multivariate analysis Cox multivariate analysis

Multivariate Multivariate analysisanalysis

HRHR IC 95% exp IC 95% exp ββ

P P valuevalue

Coapt. LengthCoapt. Length 0.820.82 [[0.63 – 0.63 – 1.001.00 ] ]

=0.05=0.05

Tips below the Tips below the annulusannulus 7.907.90 [6.52 - 9.28][6.52 - 9.28] <0.01<0.01

Residual ARResidual AR 5.305.30 [[1.47 - 1.47 - 6.576.57 ] ]

=0.01=0.01

Aortic annulusAortic annulus 1.181.18 [[1.03 - 1.03 - 2.452.45 ] ]

=0.01=0.01

Independent predictors of late AR recurrenceIndependent predictors of late AR recurrence

TEE decision chartTEE decision chart

Coaptation tips below the annulus?

No

Residual AR?

Yes

Reccurence rate: 20/28 (71%)Redo: 12/28 (43%)

No

Reccurence rate: 2/81 (2%)Redo: 1/81 (1%)

Yes

Coaptation length?

CL < 4mm

Reccurence rate: 17/36 (47%)Redo: 10/36 (28%)

CL > 4mm

Reccurence rate: 2/41 (5%)Redo: 0/41 (0%)

4-years Survival free from redo 4-years Survival free from redo

according to TEEaccording to TEE

Time (Years)0 1 2 3 4

Eve

nt F

ree

Sur

viva

l

0,0

0,2

0,4

0,6

0,8

1,0

Tips < annulus

Tips > annulus Residual AR CL < 4mm

Tips > annulus No Residual AR

Tips > annulus Residual AR CL > 4mm

Log rank p < 0.001

Example pre and immediate post Example pre and immediate post operative TEE operative TEE

of patient with late failureof patient with late failure

Pre-op TEE:Pre-op TEE: Post-op TEE Post-op TEE::

Conclusion:Conclusion:

Our results demonstrate that Our results demonstrate that intraoperative TEE can be used to intraoperative TEE can be used to

identify pts undergoing AR repair who identify pts undergoing AR repair who are at increased risk for late repair are at increased risk for late repair

failurefailure