Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) - - PowerPoint PPT Presentation

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Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) - - PowerPoint PPT Presentation

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Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR FUNDAMENTALS: 1. Pathoanatomy of different types of

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

FUNDAMENTALS: 1. Pathoanatomy of different types of BAVs 2. Mechanisms of AR 3. Morphology of BAV aortopathy THEN, HOW TO DO IT: 4. Operative techniques

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BAV (26%) vs. TAV (74%) Aortic Valve July 1993 – March 2010 (n= 242)

5 10 15 20 25 30 35 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 BAV TAV

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Stanford University CV Surgery

BAV

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Stanford University CV Surgery

Modified from Sievers, H-H. and Schmidtke, C. JTCVS 2007;133:1226 1 raphé - Type 1 2 raphés - Type 2 L - R R - N N - L lat ap L - R / R - N 0 raphé - Type 0

Main Category: Number of raphes

21(7) 14(5) 269(88) 13(4) 8(3) 216(71) 7(2) 45(15) 14(5) 1.subcategory: spatial position Of cusps in Type 0 and raphes in Type 1 and 2 2.subcategory:

V A L V U L A R F U N C T I O N

I 6(2) 1(0.3) 79(26) 22(7) 3(1) 6(2) S 7(2) 5(2) 119(39) 15(5) 3(1) 6(2) B(I+S) 1(0.3) 15(5) 7(2) 2(1) 2(1) No 3(1) 1(0.3)

Sievers’ BAV and UAV Nomenclature System

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Stanford University CV Surgery

Modified from Sievers, H-H. and Schmidtke, C. JTCVS 2007;133:1226 1 raphé - Type 1 2 raphés - Type 2 L - R R - N N - L lat ap L - R / R - N 0 raphé - Type 0

Main Category: Number of raphes

21(7) 14(5) 269(88) 13(4) 8(3) 216(71) 7(2) 45(15) 14(5) 1.subcategory: spatial position Of cusps in Type 0 and raphes in Type 1 and 2 2.subcategory:

V A L V U L A R F U N C T I O N

I 6(2) 1(0.3) 79(26) 22(7) 3(1) 6(2) S 7(2) 5(2) 119(39) 15(5) 3(1) 6(2) B(I+S) 1(0.3) 15(5) 7(2) 2(1) 2(1) No 3(1) 1(0.3)

Sievers’ BAV type for Stanford V-SARR (N=64)

28% 72%

12% 16% 65% 5% 2% 0%

0%

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Stanford University CV Surgery

Type 0 - No raphé (7%, “Naturally Perfect” BAV)

Lat (4 %) AP (2 %)

12% 16%

28%

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Stanford University CV Surgery

  • T. David V-SARR for BAV

Sievers’ type 0/lat/n

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Stanford University CV Surgery

Type 1 BAV - Single raphé (88%)

L - R (71%) R - N (15%) N - L (3%)

72%

65% 5% 2%

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Stanford University CV Surgery

  • T. David V-SARR for BAV

Sievers’ type 1/L-R/n

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Stanford University CV Surgery

  • T. David V-SARR for BAV

Annular Dilatation

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Stanford University CV Surgery

  • T. David V-SARR for BAV

Annular Dilatation

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Stanford University CV Surgery

  • T. David V-SARR for BAV

Annular Dilatation

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Stanford University CV Surgery

  • T. David V-SARR for BAV

Annular Dilatation

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Stanford University CV Surgery

N= 64 BAV patients CTA or MRA of thoracic aorta

  • Aortoventricular junction
  • Sinuses of Valsalva
  • Sinotubular junction
  • Tubular ascending aorta
  • Proximal to innominate artery
  • Distal to innominate artery
  • Proximal to LSCA
  • Distal to LSCA
  • Proximal descending aorta

J Thorac Cardiovasc Surg 135: 901, 2008

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Stanford University CV Surgery

I II III IV

Cluster I

Cluster II Cluster III

Fazel, S. et al. J Thorac Cardiovasc Surg 135:901-7, 2008

Cluster IV

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Stanford University CV Surgery

Fazel-Stanford Morphology Clusters BAV-Associated Aortopathy

Fazel, S. et al. JTCVS 135:901, 2008

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  • T. David V-SARR for BAV

Fazel-Stanford Cluster I aortopathy

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Stanford University CV Surgery

  • T. David V-SARR for BAV

Fazel-Stanford Cluster II aortopathy

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Fazel-Stanford Morphology Clusters BAV-Associated Aortopathy Transverse Arch Involvement

Fazel, S. et al. J Thorac Cardiovasc Surg 135:901, 2008

Arch dilated in 73% (types III and IV)

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Stanford University CV Surgery

Shafie S. Fazel M.D., Ph.D. (1973-2010)

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Stanford University CV Surgery

  • T. David V-SARR for BAV

Preop 4-D CTA

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

“Peninsula style” partial or total arch replacement Not the same as a “hemiarch” replacement

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Stanford University CV Surgery

“Peninsula style” partial or total arch replacement Not the same as a “hemiarch” replacement

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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NCC Suspensory cord at LCC- RCC commissure Raphé

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

Sievers type 0/ap BAV; BOTH coronary ostia are very close to the 2 commissures

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Lower suture line

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Lower suture line

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Lower suture line

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Stanford University CV Surgery

Misconceptions- lower suture line

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Cameron D and Vricella L: Op Techs Thorac Cardiovasc Surg 2005

Lower suture line Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Correct Prolapse: Cusp Free Margin Shortening

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR

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Stanford University CV Surgery

  • T. David V-SARR for BAV

Postop TTE

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  • T. David V-SARR for BAV

Discharge 4-D CTA

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Stanford University CV Surgery

Annular reduction and creation of adequate cusp coaptation height

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Stanford University CV Surgery

  • T. David V-SARR for BAV

Discharge 4-D CTA

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Stanford University CV Surgery

Key Issues Remaining Today

Patient selection Surgeons’ lack of conceptual understanding Technical pitfalls Understanding annular dilatation, cusp prolapse Unacceptably high operative mortality rate Unsatisfactory early results (learning curve) Surgeon experience Unknown durability of BAV Tirone David-V Smod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR