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Joseph E. Bavaria, M.D.Roberts-Measy Professor and Vice Chief
CardioVascular SurgeryDirector: Thoracic Aortic Surgery Program
University of Pennsylvania, USA
Rocky Valve Montana 2019
Clinical BAV Syndrome ……
(“Houston, We have a Problem!”)
1. 37 yr old Female, ICU Nurse,
2. BAV syndrome, 5 cm Ascending Aorta, Mild STJ effacement, 4.5 cm Sinus segment diameter
3. Trace to Mild AI, No AS, No gradient ……. A ‘Physiologically” Near-Normal Aortic Valve; Normal LV, No CHF, No symptoms!
Apollo 13
Bicuspid Valve and the Aorta: Effect of New guidelines?
Problem in the World
Wide Cardiac Surgery
Community …… Are we
Ready for “Prime Time”
……. No!
Estimated Number of Ascending Aorta(s) >
4.5 cm in USA!!
1 Million!
> 4.0 cm ….. 3 million (??)
Hal Dietz, MD (Johns Hopkins)
Cook AC et al. Surgical anatomy of the heart. In: Selke FW, del Nido PJ, Swanson SJ, eds.,
Sabiston & Spencer Surgery of the Chest (8ed). Philadelphia: Elsevier Saunders;2010. p.
702.
David TE. Aortic valve-sparing operations. In: Selke FW and Ruel M, eds., Atlas
of Cardiac Surgical Techniques (1ed). Philadelphia: Elsevier Saunders;2010. p.
151.
Cook AC et al. Surgical anatomy of the heart. In: Selke FW, del Nido PJ, Swanson SJ, eds.,
Sabiston & Spencer Surgery of the Chest (8ed). Philadelphia: Elsevier Saunders;2010. p.
704.
de Kerchove L and El Khoury G. Ann Cardiothorac Surg 2013;2(1):57-64.
Khelil N et al. Ann Thorac Surg 2015;99:1220-7.
Lansac E et al. Ann Cardiothorac Surg 2012;2(1):117-23.
Jeanmart H et al. Ann Thorac Surg 2007;83:S746-51.
Cusp mobility = Free margin length
Length of cusp insertion
Key Concept: The more you reduce the free margin, the less mobility
the cusp retains
Holubec T et al. Cor et Vasa 2013;55:e479-86.
Schäfers H-J et al. J Thorac Cardiovasc Surg 2006;132:436-8.
Marom G et al. J Thorac Cardiovasc Surg 2013;146:1227-31.
Average coaptation height decreases with an increase in the STJ/AA ratio
A decrease in AA diameter increases coaptation height and area
Marom G et al. J Thorac Cardiovasc Surg 2013;145:406-11.
Comparison of Post-Repair Coaptation Height: From 3D TEE and Gaussian Curves• Valve repair with simple sub-
annular reduction (SCA) • David V + Valve repair
Annular Plane Annular Plane
David V/BAV repair depicts superior achievement of coaptation line elevation above
the basal annular plane
Average coaptation height: 2.9 mm Average coaptation height: 6.0 mm
Billowing Leaflet
Goal: Great Coaptation Zone with good symmetry, no “billowing”
SCA BAV repair: mild billowing, asymmetric leaflet surface area
Series 8, image 137
Mild Billowing
Leonardo da Vinci’s Eddy Currents within the Sinuses of Valsalva
Morea M and De Paulis R. J Cardiovasc Med 2007;8:399-403.
Marfan’s Sinus of ValSalva
Aneurysm (7.0 cm.) with Severe
(+4) AI
Valve Sparing ?? Too much AI, too much aneurysmal dilation, too
much leaflet surface area,
45 mm
Near Prophylactic Replacement
Anatomical root reconstruction (facts)
Individual sinus expansion Individual sinus expansion
Optimal anatomical
proportion
Optimal anatomical
proportion
Swanson & Clark. Circ Res 1974;35:871-82.
Tailored Graft; T. Gleason
Any patient with an aortic root aneurysm and normal aortic cusps.
Acute Type A Aortic dissection—difficult but durable.
Patients with root aneurysm and abnormal cusps that are repairable.
Bicuspid aortic valve—controversial.
Severe aortic insufficiency heightens the difficulty (esp. cusp pathology).
Modifications of a straight graft for a better root reconstruction
Uni-graftCardioroot
Valsalva graft
Sievers H-H and Schmidtke C. J Thorac Cardiovasc Surg 2007;133:1226-33.
Sievers Classification
Ryan LP et al. J Thorac Cardiovasc Surg 2014;147:1103-5.
Commissural Spacing in Tricuspid and Bicuspid Valves
Still frames to depict anatomy
NOTE; Pure AI, No Calcified Leaflets
Fairly large opening, no AS
Supra coronary
aneurysm
Most Common combination
BAV Ib/c + II usually associated with 15-25% larger annulus than standard for BSA
Ring
Ring
Bavaria Edited [BAV Typically either: Ib + II or Ic +II]
de Kerchove L, El Khoury G. Anatomy and pathophysiology of the ventriculo-aortic junction: implication in aortic valve repair surgery. Ann Cardiothorac Surg. 2013;2(1):57-64.
Bavaria Algorithm 06/01/2013 [Developed based on ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Surgical Management Guidelines]
Aortic Root Options
“Florida Sleeve”
Ann Thor Surg 2009;87:11161-9
David V Subtypes with Arch
Courtesy of Stanford CV Surgery
ROBUST: Aortic Root
Reconstruction/Sinus of ValSalva Repair
Bavaria, Pochettino, Gleason, et al; Ann Thor
Surg 2003
Obliteration of Proximal False Lumen
Bavaria JE, et al; AATS 2001
Completed Root Repair and Aortic Valve
Resuspension with Neo-Media
Bavaria, Pochettino, Gleason, et al; Ann Thor Surg 2003
IMPORTANT: 72% of Aortic Roots/Valves
were NORMAL prior to Dissection!
External ring annuloplasty
Lansac E et al. Eur J Cardiothorac Surg 2006;29:537-44
External Stitch
Aicher D et al. J Thorac Cardiovasc Surg 2013;145:S30-4
17 years after reimplantation
for acute dissection
4DMRI
Comparable root anatomy Post-Procedure
Remodeling Reimplantation
Modifications of the reimplantation technique for a better root reconstruction
Cochran - 1995 David V - 2003
Gleason – 2005 Hess – 2005
Lansac – 2005Stanford mod. 2004
Rama - 2007Takamoto - 2006
JTCVS february 2019
Restoration of root and leaflet physiology
Courtesy of E. Lansac
NORMAL INDIVIDUAL AFTER REIMPLANTATION WITH SINUSES
THE ANATOMICAL ROOT RECONSTRUCTION
Result after DV: Excellent Co-aptation
Tight Acute Interleaflet triangles
Courtesy of DePaulis and Lansac
Deep Knowledge of Root Anatomy makes a difference in Valve Sparing and Repair Surgery
Must Integrate Anatomy with the Physiology (Aneurysm and AI)
A Valve Sparing operation can be “Customized” for individual patient using “Ratio Anatomy”
There are many different kinds of Operations This is a “Set-up” forvthe rest of the
Morning!
Questions?