BICUSPID AORTIC VALVE. Surgery everytime over 50 mm

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1 EuroGUCH 2017 Lousanne 5-6 May BICUSPID AORTIC VALVE Surgery everytime over 50 mm Alessandro Giamberti, MD Head Congenital Cardiac Surgery Unit IRCCS Policlinico San Donato

2 Bicuspid Aortic Valve (BAV) - affects 1-2% of the population - is the most common CHD in adults - is responsible for more death and complications that the combined effects of all the other CHD - aortic dilatation is present in 50%of pts younger than 30 and in 90% older than 80 - aortic aneurism and dissection occurr at younger age - is a risk factor for aortic dissection 5 times more often than TAV pts Bicuspid Aortic Valve = Valvuloaortopathy

3 Gradually increasing of threshould value for surgery - IRAAD data say that only 3% have BAV: is BAV really a risk factor? - Several papers say today that natural history of BAV is similar to general population in term of life expectancy

4 Statement of clarification for delineating: - Class of Recommendation - Level of Evidence J Thorac Cardiovasc Surg, April 2016

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7 In theory, theory and practice are the same. In practice, they are not! Albert Einstein

8 Without AVR With AVR JTCVS, 2013;146: the timing and technique of surgical treatment is most often dictated by surgeon preference or istitutional policy rather than being tailored to the individual patient s features and disease characteristics..even in disagreement with the current guidelines from professional societies

9 CONCOMITANT INDICATION FOR AORTIC VALVE SURGERY -Aortic stenosis in BAV have a higher risk of aortic dissection, ropture or death (BADE MATE SYNDROME) -Aortic regurgitation severity associated with degree of aortic dilatation (ROOT TYPE PATTERN) - High risk of late acute aortic syndrome Prophylactic Ascending Aorta surgery after 4.5 cm

10 50 pts with BAV submitted AVR 20 yrs mean follow-up - 10% died for acute aortic syndrome - 14% SCD - 6% reoperated for ascendig aorta aneurism (more than 6 cm)

11 ABSENCE OF VALVULAR INDICATION AND AORTA CM Additional risk factors: - Genetic - Phenotipic/Hemodinamics - Aortic coarctation - Family history of aortic dissection - Aortic growth rate 5 mm/year - Age older than 40 - Use of tobacco - Male gender

12 ABSENCE OF VALVULAR INDICATION AND AORTA CM Additional risk factors: GENETICS Systemic connective tissue abnormalities: - Marfan - Elher-Danlos - Loeys-Dietz - Turner Prophylactic Ascending Aorta surgery between 40 and 50 mm

13 ABSENCE OF VALVULAR INDICATION AND AORTA CM Additional risk factors: PHENOTYPE Type I phenotype: R-L fusion pattern Flow jet directed to the right anterior wall wich is propagated in a right handed helical direction

14 ABSENCE OF VALVULAR INDICATION AND AORTA CM Type I phenotype: R-L fusion pattern Quantification of wall remodeling phenomena by 4D Flow Study estimation of wall properties (thickness, elasticity, stiffness, and distensibility) and computation of wall stress patient-specific biomechanical simulation

15 ABSENCE OF VALVULAR INDICATION AND AORTA CM Only a matter of size? IRAAD: Acute Aortic Dissection occurred at diameters less than 50 mm in about 40% of patients

16 ABSENCE OF VALVULAR INDICATION AND AORTA CM How much is the risk of aortic catastrophe? The NUMERATOR or DENOMINATOR NEGLET PHENOMENON Pts with Ao dissection (numerator) Total n of BAV individual (denominator) - We can really count all the BAV who suffer dissection/rupture? - We only see individual who came to our medical attention OCCURRENCE OF THE EVENT RATHER THAN THE RISK OF OCCURRENCE

17 ABSENCE OF VALVULAR INDICATION AND AORTA CM Prophylactic Ascending Aorta Replacement Primum non nocere The tragedy of prophylactic surgery is that one connot distinguish those who have benefited through prevention of dissection and those who paid the price of surgery but in whom dissection would never have occured

18 ABSENCE OF VALVULAR INDICATION AND AORTA CM IS THE ACTUAL RISK OF DISSECTION BETWEEN 5.0 AND 5.5 CM LOWER THAN THE RISK ASSOCIATED WITH SURGERY? AND DO WE REALLY PREVENT DISSECTION?

19 OLMSTED COUNTY STUDY 212 BAV asymptomatic pts (15% ao dilatation) 20 yrs follow-up: 39% developed ao dilatation 27% underwent Asc Ao surgery 10 and 20 yrs survival rates of the cohort identical to control population

20 OLMSTED COUNTY STUDY This study shows that pts with BAV even with associated aortopathy, have a life expectancy identical to the general population, if careful observation and timely aneurysm surgery are performed!!

21 ABSENCE OF VALVULAR INDICATION AND AORTA CM A tailored surgical approach is today required, dictated largely by the aortopathy pattern, perioperative risk, and surgeon and centers experience WE CAN CONCLUDE THAT The risk of aortic dissection among pts with BAV and aortic aneurysm appears today to be relatively low if they are followed prospectively and if they underwent timely aorta surgery!

22 thank you very much for the attention!!