how i would like by bicuspid valve and aneurysms treated thoralf m. sundt,md aats skills april...
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How I Would Like By Bicuspid Valve and Aneurysms Treated
Thoralf M. Sundt,MDAATS SkillsApril 25,2015
First I need to know
• Do I have hypertension?
• Do I smoke?
• Does the valve function well?
• If not do I have AS or AR?
• What is the diameter of the aorta?
• What is my operative risk?
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First I need to know
• Do I have hypertension? If yes, threshold lower
• Do I smoke?
• Does the valve function well?
• If not do I have AS or AR?
• What is the diameter of the aorta?
• What is my operative risk?
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More than diameter – intraluminal pressure matters
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• Dissection is material failure when stress exceeds strength
• The Law of Laplace
T=tensionP=pressureR=radius
First I need to know
• Do I have hypertension? If yes, threshold lower
• Do I smoke? If yes, threshold lower
• Does the valve function well?
• If not do I have AS or AR?
• What is the diameter of the aorta?
• What is my operative risk?
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First I need to know
• Do I have hypertension? If yes, threshold lower
• Do I smoke? If yes, threshold lower
• Does the valve function well? If no, threshold lower
• If not do I have AS or AR?
• What is the diameter of the aorta?
• What is my operative risk?
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First I need to know
• Do I have hypertension? If yes, threshold lower
• Do I smoke? If yes, threshold lower
• Does the valve function well? If no, threshold lower
• If not do I have AS or AR? If AR, threshold lower
• What is the diameter of the aorta?
• What is my operative risk?
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Freedom from adverse aortic events in BAV stenosis vs. root phenotype patients.
Girdauskas E et al. Eur J Cardiothorac Surg 2012;42:832-838
First I need to know
• Do I have hypertension? If yes, threshold lower
• Do I smoke? If yes, threshold lower
• Does the valve function well? If no, threshold lower
• If not do I have AS or AR? If AR, threshold lower
• What is the diameter of the aorta? If > 5.0 (In my 50’s)
• What is my operative risk?
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Why 50mm? – Clearly abnormal
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First I need to know
• Do I have hypertension? If yes, threshold lower
• Do I smoke? If yes, threshold lower
• Does the valve function well? If no, threshold lower
• If not do I have AS or AR? If AR, threshold lower
• What is the diameter of the aorta? If > 5.0 (In my 50’s)
• What is my operative risk? If low, threshold lower
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How we ask the question is critical
• “At what diameter is the risk of surgery less than the risk of the disease?”
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What operation?
• If the valve functions well
• If the valve is regurgitant
• If the valve is stenotic
• If there is a neck below the innominate
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What operation?
• If the valve functions well ascending only
• If the valve is regurgitant
• If the valve is stenotic
• If there is a neck below the innominate
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The Fate of the Unreplaced Root?
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Age (yrs) 62±13
F/U period (yrs) 0-17(5±4)
Procedures N= 218
NCC procedure 15 (6.9%)
Ascending aortoplasty 65 (29.8%)
Ascending graft 153 (70.2%)
Arch surgery 13 (6.0%)
The Fate of the Unreplaced Root
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*
**
0
80
100
60
40
20
Survival (%)
0 2 4 6 8 10
Follow-up (years)
Reoperation: 10/218 (4.6%)Indication Aortic root dilation (1) Ascending aorta dilatation (2) PVE (3) PPM (2) Others (4)
What operation?
• If the valve functions well ascending only
• If the valve is regurgitant repair
• If the valve is stenotic
• If there is a neck below the innominate
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What operation?
• If the valve functions well ascending only
• If the valve is regurgitant repair
• If the valve is stenotic replace (tissue)
• If there is a neck below the innominate
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What operation?
• If the valve functions well ascending only
• If the valve is regurgitant repair
• If the valve is stenotic replace (tissue)
• If there is a neck below the innominate with a crossclamp!
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Observations: Does the Arch Dilate/Dissect?
• 470 BAV patients undergoing surgery 1988-2007
• 48 had hemiarch (10%)
• Follow-up up to 17 years, median 4.2 years
• No reoperations for arch dilatation
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Observations: Does the Arch Dilate/Dissect?
• 470 BAV patients undergoing surgery 1988-2007
• 48 had hemiarch (10%)
• Follow-up up to 17 years, median 4.2 years
• No reoperations for arch dilatation
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Observations: Does the Arch Dilate/Dissect?
• 192 patients with BAV
• 203 TAV controls
• In 49 BAV (12%) Asc Ao replaced (>4.5 cm)
• No Hemiarch/arch replacements
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Observations: Does the Arch Dilate/Dissect?
• 192 patients with BAV
• 203 TAV controls
• In 49 BAV (12%) Asc Ao replaced (>4.5 cm)
• No Hemiarch/arch replacements
The really tough question:
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By whom ?