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How I Would Like By Bicuspid Valve and Aneurysms Treated Thoralf M. Sundt,MD AATS Skills April 25,2015.

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Presentation on theme: "How I Would Like By Bicuspid Valve and Aneurysms Treated Thoralf M. Sundt,MD AATS Skills April 25,2015."— Presentation transcript:

1 How I Would Like By Bicuspid Valve and Aneurysms Treated Thoralf M. Sundt,MD AATS Skills April 25,2015

2 First I need to know Do I have hypertension? Do I smoke? Does the valve function well? If not do I have AS or AR? What is the diameter of the aorta? What is my operative risk? 2

3 First I need to know Do I have hypertension?If yes, threshold lower Do I smoke? Does the valve function well? If not do I have AS or AR? What is the diameter of the aorta? What is my operative risk? 3

4 More than diameter – intraluminal pressure matters 4 Dissection is material failure when stress exceeds strength The Law of Laplace T=tension P=pressure R=radius

5 First I need to know Do I have hypertension?If yes, threshold lower Do I smoke?If yes, threshold lower Does the valve function well? If not do I have AS or AR? What is the diameter of the aorta? What is my operative risk? 5

6 6

7 First I need to know Do I have hypertension?If yes, threshold lower Do I smoke?If yes, threshold lower Does the valve function well?If no, threshold lower If not do I have AS or AR? What is the diameter of the aorta? What is my operative risk? 7

8 First I need to know Do I have hypertension?If yes, threshold lower Do I smoke?If yes, threshold lower Does the valve function well?If no, threshold lower If not do I have AS or AR?If AR, threshold lower What is the diameter of the aorta? What is my operative risk? 8

9 Freedom from adverse aortic events in BAV stenosis vs. root phenotype patients. Girdauskas E et al. Eur J Cardiothorac Surg 2012;42:832- 838

10 First I need to know Do I have hypertension?If yes, threshold lower Do I smoke?If yes, threshold lower Does the valve function well?If no, threshold lower If not do I have AS or AR?If AR, threshold lower What is the diameter of the aorta?If > 5.0 (In my 50’s) What is my operative risk? 10

11 Why 50mm? – Clearly abnormal 11

12 First I need to know Do I have hypertension?If yes, threshold lower Do I smoke?If yes, threshold lower Does the valve function well?If no, threshold lower If not do I have AS or AR?If AR, threshold lower What is the diameter of the aorta?If > 5.0 (In my 50’s) What is my operative risk?If low, threshold lower 12

13 How we ask the question is critical “At what diameter is the risk of surgery less than the risk of the disease? ” 13

14 What operation? If the valve functions well If the valve is regurgitant If the valve is stenotic If there is a neck below the innominate 14

15 What operation? If the valve functions wellascending only If the valve is regurgitant If the valve is stenotic If there is a neck below the innominate 15

16 The Fate of the Unreplaced Root? 16

17 The Fate of the Unreplaced Root 17 * * * 0 80 100 60 40 20 Survival (%) 0 246810 Follow-up (years) Reoperation: 10/218 (4.6%) Indication Aortic root dilation (1) Ascending aorta dilatation (2) PVE (3) PPM (2) Others (4)

18 What operation? If the valve functions wellascending only If the valve is regurgitantrepair If the valve is stenotic If there is a neck below the innominate 18

19 What operation? If the valve functions wellascending only If the valve is regurgitantrepair If the valve is stenoticreplace (tissue) If there is a neck below the innominate 19

20 What operation? If the valve functions wellascending only If the valve is regurgitantrepair If the valve is stenoticreplace (tissue) If there is a neck below the innominatewith a crossclamp! 20

21 Observations: Does the Arch Dilate/Dissect? 470 BAV patients undergoing surgery 1988-2007 48 had hemiarch (10%) Follow-up up to 17 years, median 4.2 years No reoperations for arch dilatation 21

22 Observations: Does the Arch Dilate/Dissect? 470 BAV patients undergoing surgery 1988-2007 48 had hemiarch (10%) Follow-up up to 17 years, median 4.2 years No reoperations for arch dilatation 22

23 Observations: Does the Arch Dilate/Dissect? 192 patients with BAV 203 TAV controls In 49 BAV (12%) Asc Ao replaced (>4.5 cm) No Hemiarch/arch replacements 23

24 Observations: Does the Arch Dilate/Dissect? 192 patients with BAV 203 TAV controls In 49 BAV (12%) Asc Ao replaced (>4.5 cm) No Hemiarch/arch replacements 24

25 The really tough question: 25 By whom ?

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