how i would like by bicuspid valve and aneurysms treated thoralf m. sundt,md aats skills april...

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?

2

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?

3

More than diameter – intraluminal pressure matters

4

• 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?

5

6

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?

7

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?

8

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?

10

Why 50mm? – Clearly abnormal

11

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

12

How we ask the question is critical

• “At what diameter is the risk of surgery less than the risk of the disease?”

13

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

14

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

15

The Fate of the Unreplaced Root?

16

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

17

*

**

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

18

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

19

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!

20

21

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

22

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

23

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

24

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:

25

By whom ?