Joseph E. Bavaria, M.D. Roberts-Measy Professor …...Surgery Must Integrate Anatomy with the...

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?