Joseph E. Bavaria, M.D. Roberts Measy Professor and Vice Chief CardioVascular Surgery Director: Thoracic Aortic Surgery Program University of

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1 Joseph E. Bavaria, M.D. Roberts Measy Professor and Vice Chief CardioVascular Surgery Director: Thoracic Aortic Surgery Program University of Pennsylvania, USA North American Valve Repair, Philadelphia May 2015

2 2002 to 2015: 963 patients with Bicuspid Aortic Valve Disease (the surgical practice BAV universe) *AS ± AI or AI for isolated AVR (N=654) EXCLUDED Valve Pathology (N= 963) AI ± aortic root aneurysm (N=309) Primary Leaflet Repair ± Ascending Aorta Replacement (N=61) Since 2005 Total BAV Repair = 111 Primary Leaflet Repair + Root Reimplantation (N=50) Bentall or Proximal Aortic Reconstruction (N=198) Since 2006 Bavaria, JE 4/2015

3 What about AI? BAV Repair Philosophy: The Basics for AI In Evolution

4 Pictures courtesy of G. El-Khoury Type 0 (true) 0 Type 1 (prolapsing) Type 1 (restrictive) (Sievers et al. JTCVS 2007)

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6 Clinical BAV Syndrome ( Houston, We have a Problem! ) Apollo 13 Bicuspid Valve and the Aorta: Effect of New guidelines? 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!

7 Problem in the World Wide Cardiac Surgery Community Are we Ready for Prime Time. No!

8 Most Common combination BAV Ib/c + II usually associated with 15-25% larger annulus than standard for BSA

9 Einstein: Make everything as simple as possible But No Simpler!!

10 At this time we almost never replace an insufficient Mitral Valve Repair So. For AI Aortic Valves Repair and Preserve Native Cusp (leaflet) tissue Restore the Normal 3D Geometry of the Root or the Functional Aortic Annulus (the Annulus and STJ)

11 BAV with AI and relatively normal Root diameters BAV with AI and relatively normal Root diameters but Ascending Aneurysm BAV with AI and Root Dilation Problem: different theraputic procedures for each presentation??

12 Supra coronary aneurysm

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14 Preoperative TEE: BAV, Severe AI, Normal Aorta Diameters but Very Large annulus

15 Preoperative TEE: Aortic Diameters

16 BAV with AI and relatively normal Root diameters BAV with AI and relatively normal Root diameters but Ascending Aneurysm BAV with AI and Root Dilation Problem: different theraputic procedures for each presentation??

17 Concept of Sino-Tubular Definition

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19 Normal Sinus Diameter

20 BAV with AI and relatively normal Root diameters BAV with AI and relatively normal Root diameters but Ascending Aneurysm BAV with AI and Root Dilation Problem: different theraputic procedures for each presentation??

21 NOTE; Pure AI, No Calcified Leaflets Fairly large opening, no AS Still frames to depict anatomy

22 Supra coronary aneurysm

23 Implantation of the neoroot A V-shaped Cut in the NeoRoot to account for the Left/Right Aorto-PA Conus fixation Completion of El Khoury leaflet repair David V reimplantation and graft-to graft proximal aortic reconstruction

24 Supra coronary aneurysm

25 Place Sub-annular exactly like the Reimplantation (DV) but for external ring only: The Root is normal

26 Courtesy G. El-Khoury Bicuspid Valve Type 1? or 2?

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29 But.What kind of Reconstructive Operation are we Talking about?

30 NOTE; Pure AI, No Calcified Leaflets Fairly large opening, no AS Still frames to depict anatomy

31 Basic Pre op TEE Assessment

32 Preoperative TEE

33 Preoperative TEE BAV repair (pre op assessment of Perimeter

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38 Use 7-0 prolene to Mark the leaflet edges and therefore define the necessary redundant segment

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40 BAV Repair with Resection (not Plication) of calcified thickened Raphe

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42 Usually done at beginning.

43 This is when we make 210/150 vs 180/180 decision!

44 Coronary Buttons are cut. 210/150 perimeter and Leaflet surface area ratios.

45 Another Example

46 Institutional Approach to BAV syndrome with Aortic Insufficiency (AI) Type I BAV Nonaneurysmal root Aneurysmal root Repair + SCA Repair + RR About 50:50 in our practice

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49 SCA BAV repair: mild billowing, asymmetric leaflet surface area Series 8, image 137

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51 2mm below the leaflet insertion; Special attention to Right Cusp.

52 In BAV: Size the annulus for the normal annular diameter for each individual 210º/150º Neo ValSalva Root (Raphed BAV)

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54 Goal: Great Coaptation Zone with good symmetry, no billowing

55 Outcomes with BAV Repair + Root Reimplantation: How do they compare to our institutional tricuspid aortic valve root reimplantation?

56 Freedom from AI >2+ (%) 5 years Log-Rank P = 0.7

57 LV Remodeling: Excellent in Both groups LV end-diastolic diameter (mm) BAV TAV BAV: 57 to 51 mm p =<0.01 TAV: 53 to 50 mm p = < Preoperative Follow up

58 Substantial Thickening and Calcification BUT an AI presentation: Not Really repairable WITHOUT resection and Pericardial patch augmentation..

59 What Gold Standard Operation are we Talking about? Comparing The Re-implantation BAV root to Bentall Classic Bentall (Mechanical Composite graft) Bio-Bentall

60 Proposed surgical management strategy for BAV AI repair (present algorithm as of 6/2013).. Nuances

61 Supra coronary aneurysm There are MAJOR differences of Opinion regarding this Category

62 BAV repair is very feasible with very good mid-term outcomes With minimal leaflet Calcification Either 210/150 or 180/180 orientation is reasonable depending on pre-operative perimeter assesment Annular Stabilization is Critical Re-Implantation (or Sub-annular Ring) accomplishes this goal. Simple SCA in pre-op Annular diameters >27 should be abandoned Reconstructive principles need to be vigorously upheld

63 Thank You Great Progress in 10 years!