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Tailored Cusp Extension Valvuloplasty for Aortic Valve Reconstruction in Children

Monday, October 27, 2014

Objective: Aortic valve repair has encouraging mid- and long-term results in selected patients. This video describes the tailored cusp extension valvuloplasty surgical technique.

Methods: A 15-year-old girl presented with severe aortic valve regurgitation, moderate stenosis, and a dilated left ventricle. She was referred for cusp extension valvuloplasty. A large segment of anterior pericardium was very carefully prepared (the loose fatty areolar tissue was bluntly dissected away) and harvested. The free edge length and height of each cusp, as well as the diameter of the sinotubular junction and aortic annulus, were measured and used to tailor three pericardial patches.

Results: Postoperative echocardiogram showed trivial aortic regurgitation with no stenosis. The patient was rapidly extubated and had an uncomplicated post-operative course. She was doing well at one year follow-up exam.

Conclusions: Tailored aortic cusp extension provides excellent valve repair in a large proportion of children with rheumatic aortic regurgitation.

Comments

Congratulation for the results. I wonder about the longevity of the cusps with the on going rheumatic reaction . Is there a limit on the lab tests that indicates an ongoing rheumatic reaction or the so called "chronic rheumatic fever" that limit the durability of this technique?. Do you keep penicillin coverage ? At till what age?.
Congratulation for the results. I have no doubt about the longevity of the autologous pericardial valve as it is well shown already in the papers (Dr. Ozaki and Dr. Al Halees). The problem is to have a universal and easy method for intra-operative patch trimming. Please refer to my method of determination of aortic valve parameters for its total autologous reconstruction (JThCVS, 2000; 119: 386 - 387). I think my method is very simple, precise and reproducible. There is no need for any templates and devices. All you need is to measure the three intercommissural distances and then using my formulas find the leaflets parameters.
Thanks for posting the video. I enjoyed it greatly. I have been doing similar procedures for aortic stenosis and regurgitation . congenital and acquired, including tricuspidizaztion and leaflet extension in pediatric patients. I have a few questions: 1- after the repair, what was the findings that necessitate re-operation? 2- for fresh autologous pericardial leaflet extension. what was the findings at re-operation? were you able to look at histological changes in these patches? I had a patient whose pericardial extension has become very thickened and newly developed regurgitation after more than a year. 3- would you re-repair ? Thanks Khanh Nguyen MD Mt Sinai Hospital NY, USA
Thank you for the very positive comments! Aortic valve reconstruction with cusp extension patches suffers from two issues, as outlined by the comments above: first reproducibility, by standardizing sizing of the patches, and second by the shortfalls of the patch materials we have at our disposal. For Dr Gasparyan: indeed, there are many ways to size extension patches. We believe our method is very reproducible, although it remains custom-made. Your technique is indeed an alternative. There has been increasing interest in the Ozaki procedure, using sizers to completely replace the leaflets with (reproducible) patient tailored patches. Although this makes sizing of the patches completely and perfectly reproducible, as long as the technique has been well taught and proctored, I worry that no autologous tissue is left. This may be considered an advantage, but in my humble opinion, this leaves any growth potential of the repaired valve on the patch material, which for the moment is limited. Furthermore, this represents something closer to a standardized and customized stentless valve replacement to a reconstruction. For Dr Nguyen: the mechanism of failure differed depending on patch materials: for glutaraldehyde-fixed bovine pericardium, calcification of the patch, for fresh autologous pericardium, fibrosis and retraction of the patch material, and for Photofix pericardium, the patches were mostly intact (except 1 patient, with very thickened extensions), with either annular dilatation and central regurgitation, or retraction of the native leaflets due to ongoing rheumatic degeneration. We indeed looked at histology, as outlined in our paper in WJPCHS. Most of our reoperations have been in older children or adolescents, and a valve replacement was considered the most durable option. If it's a small child, we would consider a re-repair, as there are few other options and buying as much as time as possible until an eventual valve replacement with a larger prosthesis is our strategy. I am particularly interested in the data coming out on CardioCel patches for valve repair, notably from the experience of the group from Melbourne, and now the group from Munich with the Ozaki operation, although this is very preliminary experience with this patch material (disclosure: I have served on their scientific advisory board of Admedus, which makes the CardioCel patches).

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