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

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Presentation transcript:

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

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

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

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

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

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

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

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

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

Why 50mm? – Clearly abnormal 11

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

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

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

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

The Fate of the Unreplaced Root? 16

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

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

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

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

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

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

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

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

The really tough question: 25 By whom ?