1. Trileaflet Aortic Valve

2. Management strategy for patients with chronic severe aortic regurgitation. Preoperative coronary angiography should be performed routinely as determined by age, symptoms, and coronary risk factors. Cardiac catheterization and angiography may also be helpful when there is discordance between clinical findings and echocardiography. “Stable” refers to stable echocardigraphic measurements. In some centers, serial follow-up may be performed with radionuclide ventriculography (RVG) or magnetic resonance imaging (MRI) rather than echocardiography (Echo) to assess left ventricular (LV) volume and systolic function. AVR indicates aortic valve replacement; DD, end-diastolic dimension; EF, ejection fraction; eval, evaluation; and SD, end-systolic dimension. Severe Aortic Regurgitation

3. Case #1 u u 78 year old woman admitted to hospital in heart failure. Found to have trileaflet Aortic valve with severe aortic insufficiency and reduced LV function. EF 20-25%. Aortic Valve gradient mean 5.2 mmHg. u u Aortic Root: Surgical Annulus2.1cm Sinus of Valsalva2.9cm STJ1.8-2.0cm

4. LT 02

5. LT 04

6. LT 30

7. Case #1 u u Surgery placement #19 Medtronic supra-annular valve Mean Gradient 8.8mm Hg Peak Gradient 17mm Hg

8. Management strategy for patients with severe aortic stenosis. Preoperative coronary angiography should be performed routinely as determined by age, symptoms, and coronary risk factors. Cardiac cathereterization and angiography may also be helpful when there is discordance between clinical findings and echocardiography, Modified from CM Otto. Valvular aortic stenosis; disease severity and timing of intervention. J Am Coll Cardiol 2006;47:2141-51(149). AVA indicate aortic valve area; BP, blood pressure; CABG, coronary artery bypass graft surgery; echo, echocardiography; LV, left ventricular; and Vmax, maximal velocity across aortic valve by Doppler echocardiography. Severe Aortic Stenosis

9. Case #2 u u 83 y/o male with know aortic stenosis progressed in symptoms with SOB and fatigue. In past had stent to LAD. More recently angina with exertion, LAD now with 70% in stent stenosis. Periods of rapid atrial fibrillation. Dynamic LV function recently as low as 30%. Aortic valve gradient mean 37mmHg, peak 70mmHg. u u Aortic Root: Surgical Annulus2.4cm Sinus of Valsalva3.2cm STJ2.6cm

10. IH 01

11. IH 02

12. IH 03

13. IH 09

14. IH 12

15. IH 14

16. Case #2 Procedure: 1) 1) Pulmonary Vein Isolation Ganglionic Ablation Marshall Vein Ablation 2) 2) CABG x 1 LIMA to LAD 3) 3) AVR #25 Hancock II Bioprosthesis

17. IH 30 Case #7 Post Procedure Echo

18. Case #3 Aortic Root Valve Sparing Reconstruction u u 53 year old man with elevated cholesterol underwent Cardiac CT for coronary calcium scoring. Found to have dilated aortic root. Trivial to mild aortic insufficiency. Coronaries clear on cath. u u Trileaflet aortic root:Surgical Annulus 2.3cm Sinuses of Valsalva 5.3cm STJ 4.2cm Ascending Aorta 3.5cm

19. JH 01

20. JH 10

21. JH 04

22. JH 05

23. JH 07

24. JH 09

25. JH 13

26. JH 14

29. Case #3 Aortic Root Valve Sparing Reconstruction u u Underwent valve sparing aortic root reconstruction with #26 Dacron graft using Yacoub technique.

30. JH 44 Case #8 Post Procedure Echo

31. JH 45 Case #8 Post Procedure Echo