2 nd AVRS 2016: Nimesh D. Desai, M.D., Ph.D. Co Director, Aortic and Vascular Center for Excellence University of Pennsylvania
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1 2 nd AVRS 2016: Nimesh D. Desai, M.D., Ph.D. Co Director, Aortic and Vascular Center for Excellence University of Pennsylvania
2 Knowing what to Do Know what NOT to Do The Exquisite art of Timing.
3 or is this an example of what NOT to do? AATS Aortic Symposium 2016
4 Key issues: Calcification, leaflet augmentation Fenestrations BAV vs TAV : What are the long term results Who wants a bicuspid Valve anyway? IS TAVR REALLY VIABLE in BAV
5 Use of Pericardial Patch for Reconstruction Substantial Thickening and Calcification BUT an AI presentation: Not Really repairable WITHOUT resection and Pericardial patch augmentation..
6 Actuarial freedom from reoperation after aortic valve repair in patients with a BAV depending on the use of a pericardial patch. Aicher D et al. Circulation 2011;123:
7 Boodhwani M, de Kerchove L, Glineur D et al. Repair of regurgitant bicuspid aortic valves: A systematic approach. J Thorac Cardiovasc Surg 2010; 140: In patients requiring raphe repair, use of a patch was associated with greater recurrence of AI (**p=.02).
8 Kunihara T Schafers HJ et al. JTCVS year freedom from recurrent AI>2+: 88.9% ± 2.5% ( 28 mm) vs 69 ± 8% 28 mm Predictors of BOTH late recurrent AI>2+ and Reoperation: AVJ diameter >28 mm Effective height <9 mm Use of pericardial patch
9 Impact of Fenestrations in TAV Hans-Joachim Schäfers, Frank Langer, Petra Glombitza, Takashi Kunihara, Roland Fries, Diana Aicher The Journal of Thoracic and Cardiovascular Surgery, Volume 139, Issue 3, 2010,
10 Patch Repair of Fenestrations David Nezhad, El Khoury EJCTS 2014 Shafers et al 2009
11 49 yo male Severe AI with dilated ventricular diameters (LVEDd = 3.6 cm) NYHA: Class I
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17 60 yo male Moderate severe AI with mildly dilated ventricular diameters (LVEDd >6 cm) NYHA: Class II
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22 Outcomes with BAV Repair / Root Reimplantation: How do they compare to tricuspid aortic valve root reimplantation?
23 Should we even repair BAV Dr. Bavaria. Any purely insufficient valve with enough leaflet surface area can be repaired We are getting close MAR 2014, PARIS FRANCE AATS discussion 2011
24 5 yrs: 95 ± 1.3% 10 yrs: 90 ± 3% Preoperative AI was not a risk factor for AV replacement. HR 2.1; p=0.2 Similar. Price J et al. Risk of valve related events after aortic valve repair. Ann Thorac Surg.2013 Feb;95(2):
25 PENN: Root Reimplantation Outcomes: Bicuspid Aortic Valve vs. Tricuspid Aortic Valve Outcomes are similar.
26 Importance of Preop AI: More severe AI was highly Associated with early failure No influence of TAV vs BAV
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28 (A) Commissural Repair sutures for most repairs (B) Mobilization of commissures for a large root (C) Closure of gaps in aortic root (D) Reattachment of commissures resuspended at a higher level in ascending aorta tube graft Svensson LG, Al Kindi AH, Vivacqua A et al. Long-Term Durability of Bicuspid Aortic Valve Repair. Ann Thorac Surg 2014; 97:
29 Svensson LG, Al Kindi AH, Vivacqua A et al. Long-Term Durability of Bicuspid Aortic Valve Repair. Ann Thorac Surg 2014; 97:
30 Svensson LG, Al Kindi AH, Vivacqua A et al. Long-Term Durability of Bicuspid Aortic Valve Repair. Ann Thorac Surg 2014; 97:
31 If you make the hole small enough, you can completely eliminate any regurgitation and replace it with stenosis
32 Svensson LG, Al Kindi AH, Vivacqua A et al. Long-Term Durability of Bicuspid Aortic Valve Repair. Ann Thorac Surg 2014; 97:
33 Who Wants a BAV anyway?? Techniques have evolved to enable repair of the most complex pathologies Kari, Miller JTCVS 2012 But the patient still Has a BAV..
34 Natural History Olmsted County >3 <3 Thickening, calcification, and reduced mobility. Kari, Miller JTCVS 2012 Michelina, Sarano Circulation (normal) 1 (mild alteration) 2 (moderate alteration) 3 (severe alteration)
35 The Alternative is not a FAILURE!!! Excellent Aortic Root outcomes in patients < 60
36 Area ~ S3??
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39 Pericardial patch leaflet augmentation may have longerterm durability issues Fenestrations may limit repair possibilities in TAV Repair BAV results, in most (but not all) series, are equivalent to TAV repair Still no data that BAV repair is equivalent/better than replacement strategies in the TAVR era: Has the field evolved enough to look at performing RCTs?
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