Bicuspid Aortic Stenosis
(New Surgical Approaches)
Joseph S. Coselli, M.D.
Professor and Cullen Foundation Endowed Chair
Division of Cardiothoracic Surgery
Baylor College of Medicine
Heart Valve Summit 2013
Session II: New Treatment Approaches
Chicago, IL • Thursday, September 26, 2013
Conflict of Interest
Medtronic, Inc.
Vascutek Terumo
WL Gore & Associates
Research Support, Honorarium,
Consultant, Speaker
Educational Grant, Consultant,
Royalties, Speaker
Research Support, Advisory
Board
Calcified Bicuspid Aortic Valves
Images: Heart-Valve-Surgery, Library.Med.Utah, Ho 2008 EJ Echo, Robertson 2012
What’s new in surgical
approaches to bicuspid
aortic stenosis?
WTF?
What’s new in surgical
approaches to bicuspid
aortic stenosis?
**$@!!@!
Bicuspid Aortic Valves
• Common (1-2% of population)
• A third → valve complication
• A third to half → aortic dilatation
Tricuspid AV
Bicuspid AV
Bicuspid Aortic Valves
Type II
TAV
Type III
Type I
Most Common ~80%
~1%
• Common (1-2% of population)
 3-6 million US citizens affected (males 4:1)
 Congenital or acquired (functional)
• A third → valve complication
• A third to half → aortic dilatation
Images from Abdulkarrem 2013 ICVTS
Bicuspid Aortic Valves
• Common (1-2% of population)
• A third → valve complication
 Aortic valve stenosis (AS)
most common valve complication
 Aortic valve insufficiency (AI)
 AS mixed with AI
 None: functionally normal
• A third to half → aortic dilatation
Bicuspid Aortic Valves
• Common (1-2% of population)
• A third → valve complication
• A third to half → aortic dilatation





Ascending aorta is often affected
With and without involving the aortic root
Aortic arch may be additionally affected
Distal aorta rarely affected
Varying patterns of dilatation
13%
14%
28%
45%
Great heterogeneity
Fazel 2008 JTCVS
Heterogeneity: A Tale of 2 Brothers with BAV
Stenosis
Rapid progression of
symptoms during
last month of life
•breathlessness
•dizziness
•peak gradient of 56
mmHg
•mean gradient of
39 mmHg
•AVA 0.6 cm2
•Repair performed,
but he died 2 weeks
later
Normal
Deceased Age 16
Deceased Age 21
No evidence of
cardiac dysfunction.
Dissection following
amphetamine use
•5 cm tear
•dilated ascending
aorta
•severe coarctation
•normally
functioning valve
•leaflets soft and
pliable
•Found dead
Variability Within Same Family
Zafar Proc BUMC 2013;26:171-173 Case report of 2 brothers with congenital BAV
Aortopathy Associated with
Complications of Aortic Valve
Stenosis
Supracoronary
Aneurysm
Insufficiency
Annuloaortic Ectasia
(Marfan Syndrome)
Both
Tubular Diffuse
Enlargement
Differing
Embryogenesis
• The ascending aorta
and aortic arch are
derived from
Neural Crest Cells
• The distal aorta is
derived from the
Mesoderm
The descending aorta in a murine model
is indicated to be free of neural crest
cells, unlike the aortic root and arch.
Bergwerff Circ Res 1998
Leroux-Berger JBMR 2011 [France]
Nakamura Circ Res 2006
Many BAV Associated Genes
Multiple genes associated with BAV; Decreased penetrance of BAV
Abdulkareem ICVTS 2013
Many BAV Associated Genes
Not a single-gene mutation!
Greatly enhances complexity
Most mutations are sporadic (91%)
A few mutations are familial (~9%)
Multiple genes associated with BAV; Variable penetrance of BAV
Abdulkareem ICVTS 2013
Driver of BAV Aortopathy?
Controversy!!!
Flow hypotheses
• Hemodynamic
flow
• Tissue fundamentally
disturbance
different from normal
weakens
aortic tissue, not unlike
aorta
Marfan syndrome
• Turbulent
• Ascending aorta
blood flow
susceptible to mutation in passing
neural crest (cell origins)
through valve
affects
ascending
aorta
Genetic abnormality
Plaisance 2012
Aortic Tissue Properties → BAVs
•
Medial degeneration with
loss of elastic fibers
• Loss and reorientation of
smooth muscle cells
• Less type I collagen
• Fibrillin -1 deficiency
Normal Aorta
•
•
•
Extracellular matrix disrupted
MMP increased, ↑degradation
ECM proteolytic cascade altered
 Tamarina 1997 Surgery
 de Sa 1999 JTCVS
 Bauer 2002 ATS
BAV Aorta
Della Corte et al ▪ J Heart Valve Dis 2006
Fedak et al ▪ Circulation 2002
LeMaire J Surg Res 2005
Bicuspid
Tricuspid
MMP-2 (Immunohistochemical staining)
• MMP-2 Significantly
increased in BAV
LeMaire J Surg Res 2005
Control
Bicuspid
Tricuspid
MMP-9 (Immunohistochemical staining)
• MMP-9 Significantly
decreased in BAV
LeMaire J Surg Res 2005
Control
BAV: Aortic Stenosis
• Some inherent dysfunction • In adults, most AS is due
to leaflet calcification
as bicuspid valve opens
• Often calcification is
abnormally even without
rapid and severe
symptoms
Normal valve opens
& closes quickly.
Fibrosis/calcification are common
Fusion of the right and left cusp
Voigt ▪ 2010 ; Ionasec ▪ 2010
Images: Roberts Medicine 2012
BAV Calcification:
Macrophage
Infiltration
Bicuspid
• Mechanism for rapid
progression of BAV stenosis?
• Neovascularizaion and
macrophage infiltration >
BAV
Inflammation
(P = .002)
Bicuspid Tricuspid
Tricuspid
Neovascularization
(P = .0005)
Bicuspid Tricuspid
Moreno 2011 JTCVS; 142:895-901; Comparison of excised leaflets of stenotic TAV and BAV
BAV: Aortic Dissection
Most significant potential
complication in BAV is acute
ascending dissection
8-fold increased risk!
Michelena JAMA 2011;306:1104-12
• BAV patients with AS are at far
greater risk of aortic dissection
than TAV patients
86 Mayo Clinic patients with type A dissection
19% BAV have ≥ 40 mmHg mean gradient
0% TAV have ≥ 40 mmHg mean gradient
Eleid Heart 2013 in press
288 Chinese patients with type A dissection
23% BAV have > 25 mmHg mean gradient
0% TAV have > 25 mmHg mean gradient
Wang EFCTS 2013;44:172-77
Type A dissection at RCA
in patient with AS and endocarditis
Non-Right cusp fusion
Iwasa ICVTS 2011
Aortic Dilatation in BAV Stenosis
Ascending
Significant
Subset of patients with
Severe AS
Ascending
Significant
Subset of patients with
Mild/mod AS
Patients with stenotic BAVs have greater dilation of the
ascending aorta than do stenotic TAV patients
• Dilatation ≥ 5.0cm was 35% in BAV and 4% in TAV
84 BAV pts vs 103 TAV pts
Debl 2009 Clin Res Cardiol
BAV: Aortic Stenosis
• BAV is present in about
50% of all adult cases of
aortic valve stenosis
• Process is similar to
senile degenerative AS
but happens decade
earlier in BAV patients
52% of all cases of AS
in patients < 80 years
Roberts Am J Cardiol2012;109:16321636
Patients from 1993 to 2011 with excised
native stenotic aortic valves (with or
itho t AI)
1725 patients
Treatments for Aortic Stenosis
Treatment of
predominantly
or purely calcific
valve stenosis
has always been
problematic
Investigated Treatments
•Decalcification
 Open manual debridement,
surgical valvuloplasty,
sculpturing (1950s-60s)
 Laser/ultrasonic debridement
(1980s-2000s)
• Dental plaque fragmentizers
• Urologic instruments for kidney stones
• Cavitron surgical aspirator (CUSA)
Fix it?
Ultrasonic Decalcification
•
•
•
•
Investigated as treatment for calcification/stenosis
Late insufficiency due to retraction of cusps
Tendency towards recalcification of leaflets
Technique largely abandoned
Williamson Lasers Surg Med 1993;13:421-8.
Dahm J Heart Valve Dis 2000;9:21-6.
Kellner EJCTS 1996;10:498-504.
Freeman JACC 1990:16:623-30.
Expert Guidelines
for Valvular Heart
Disease
In Setting of BAV
Condition of ascending aorta/aortic root
> 5.0 cm
Fast growing (≥ 0.5 cm per year)
Concomitant repair of valve
And ascending aorta/root > 4.5 cm
Patient is of small stature
Same as 2006 guidelines
Bonow 2008 JACC
Guidelines
Replace aorta
Replace aorta
Replace aorta
Consider
lowered
threshold
Class I Level C Recommendations
Expert Aortic
Guidelines
Bicuspid aortic valve
recommendations
Condition of ascending aorta/aortic root
4.0 ↔ 5.0 cm
Fast growing (≥ 0.5 cm per year)
Concomitant repair of valve
And ascending aorta/root > 4.5 cm
Guidelines
Replace aorta
Replace aorta
Replace aorta
Class I Level C Recommendations
Hiratzka 2010 Circulation
European Heart Journal (2012) 33, 2451–2496
doi:10.1093/eurheartj/ehs109
ESC/EA CT S GU IDELIN ES
Guidelines on the management of valvular heart
disease (version 2012)
T he Joint Task For ce on t he Managem ent of Valvular Hear t Disease
of t he Eur opean Societ y of Car diology (ESC) and t he Eur opean
A ssociat ion for Car dio-T hor acic Sur ger y (EACT S)
Aut hor s/T ask For ce Mem ber s: Alec Vahanian (Chair per son) (Fr ance) * , Ot t avio Alfier i
(Chair per son) * (It aly), Felicit a Andr eot t i (It aly), Manuel J. A nt unes (Por t ugal ),
Gonzalo Bar ón-Esquivias (Spain), Helm ut Baum gar t ner (Ger m any),
Michael Andr ew Bor ger (Ger m any), T hier r y P. Car r el (Swit zer land), Michele De Bonis
(It aly), A r t ur o Evangelist a (Spain), Volkm ar Falk (Swit zer land), Ber nar d Iung
(Fr ance), Pat r izio Lancellot t i (Belgium ), Luc Pier ar d (Belgium ), Susanna Pr ice (UK),
H ans-Joachim Schäfer s (Ger m any), Ger har d Schuler (Ger m any), Janina St epinska
(Poland), Kar l Swedber g (Sweden), Johanna T akkenber g (T he N et her lands),
U lr ich O t t o Von O ppell (U K), St ephan W indecker (Swit zer land), Jose Luis Zam or ano
(Spain), Mar ian Zem bala (Poland)
Expert Valvular
Guidelines
In Setting of BAV
Condition of ascending aorta/aortic root
Guidelines
regardless of valvular disease
≥ 50 mm with additional risk factors
Consider surgery
Risk factors: coarctation of the aorta, systemic
hypertension, family history of dissection or
increase in aortic diameter > 2 mm/year*
ESC Com m it t ee for Pract ice Guidelines (CPG): Jer oen J. Bax (Chair per son) (The N et her lands), H elm ut Baum gar t ner
(Ger m any), Claudio Ceconi (It aly), Ver onica Dean (Fr ance), Chr ist i Deat on (UK), Rober t Fagar d (Belgium ),
Chr ist ian Funck-Br ent ano (Fr ance), David Hasdai (Isr ael ), Ar no Hoes (The N et her lands), Paulus Kir chhof
(Unit ed Kingdom ), Juhani Knuut i (Finland), Philippe Kolh (Belgium ), T her esa McDonagh (UK), Cyr il Moulin (Fr ance),
Bogdan A . Popescu (Rom ania), Željko Reiner (Cr oat ia), Udo Secht em (Ger m any), Per Ant on Sir nes (N or way),
Michal Tender a (Poland), A dam Tor bicki (Poland), A lec Vahanian (Fr ance), St ephan W indecker (Swit zer land)
Docum ent Reviewer s:: Bogdan A . Popescu (ESC CPG Review Coor dinat or ) (Rom ania), Ludwig Von Segesser (EACT S
Review Coor dinat or ) (Swit zer land), Luigi P. Badano (It aly), Mat jaž Bunc (Slovenia), Mar c J. Claeys (Belgium ),
N iksa Dr inkovic (Cr oat ia), Ger asim os Filippat os (Gr eece), Gilber t Habib (Fr ance), A . Piet er Kappet ein (T he N et her lands),
Roland Kassab (Lebanon), Gr egor y Y.H. Lip (UK), N eil Moat (U K), Geor g N ickenig (Ger m any), Cat her ine M. Ot t o (USA ),
John Pepper , (U K), N icolo Piazza (Ger m any), Pet r onella G. Pieper (T he N et her lands), Raphael Rosenhek (A ust r ia),
N alt in Shuka (A lbania), Ehud Schwam m ent hal (Isr ael ), Juer g Schwit t er (Swit zer land), Pilar Tor nos Mas (Spain),
Pedr o T. Tr indade (Swit zer land), T hom as W alt her (Ger m any)
T he disclosur e for m s of t he aut hor s and r eviewer s ar e available on t he ESC websit e www.escar dio.or g/guidelines
Online publish-ahead-of-print 24 August 2012
* Corresponding authors: Alec Vahanian, Service de Cardiologie, Hopital Bichat AP-HP, 46 rue Henri Huchard, 75018 Paris, France. Tel: + 33 1 40 25 67 60; Fax: + 33 1 40 25 67 32.
Email: alec.vahanian@bch.aphp.fr
Ottavio Alfieri, S. Raffaele University Hospital, 20132 Milan, Italy. Tel: + 39 02 26437109; Fax: + 39 02 26437125. Email: ottavio.alfieri@hsr.it
†Other ESC entities having participated in the development of this document :
Associations: European Association of Echocardiography (EAE), European Association of Percutaneous Cardiovascular Interventions (EAPCI), Heart Failure Association (HFA)
Working Groups: Acute Cardiac Care, Cardiovascular Surgery, Valvular Heart Disease, Thrombosis, Grown-up Congenital Heart Disease
Councils: Cardiology Practice, Cardiovascular Imaging
The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the
ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford
University Press, the publisher of the European Heart Journal, and the party authorized to handle such permissions on behalf of the ESC.
Disclaim er . The ESC/EACTSGuidelines represent the views of the ESC and the EACTSand were arrived at after careful consideration of the available evidence at the time they
were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual
responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient and, where appropriate and
necessary, the patient’s guardian or carer. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of
prescription.
& The European Society of Cardiology 2012. All rights reserved. For permissions please email: journals.permissions@oup.com
Vahanian 2012 Eur Heart Journal
*on repeated measurements using the same
imaging technique, measured at the same aorta
level with side-by-side comparison and
confirmed by another technique
Expert Aorta and
Ascending Guidelines
In Setting of BAV
Condition of ascending aorta/aortic root
> 5.0 cm
Family history of dissection And > 4.5 cm
Fast growing (≥ 0.5 cm per year)
Concomitant cardiac repair
And ascending aorta/root > 4.5 cm
Guidelines
Consider surgery
Consider surgery
Consider surgery
Consider surgery
Ratio ascending aortic diameter to height > 10
Without significant aortic root dilatation
Consider surgery
Consider Wheat
Level B Recommendations
Svensson Ann Thorac Surg 2013;95:S1-66
Expert Aorta and
Ascending Guidelines
Management of BAV Not
Meeting Other Criteria
All patients with BAV
Level B evidence
First-degree relatives of young patients
with BAV
Level C evidence
Svensson Ann Thorac Surg 2013;95:S1-66
Guidelines
Undergo imaging of
thoracic aorta
Advise further
investigation
Repair of Bicuspid Aortic Valves
• Bicuspid valves are frequently repaired




32 of 374 pts (13%) David 2013 [Toronto]
17 of 55 pts (31%) Boodhwani 2011 [El Khoury]
Entire series of 75 patients Kari 2013 [Stanford]
Entire series of 153 patients Schäfers 2010[Saar]
• When to consider repair
 Pliable leaflets
Which BAVs can
 Minimal fibrosis and calcification be repaired rather
 No more than mild cusp thickening than replaced?
 Regurgitant valves (even if severe)
 Normally functioning valves
 Minor fenestrations
Gleason STCVS 2006 Kari 2013 JTCVS (Stanford)
374 patients
13% BAV
Freedom from Reoperation
Balloon Valvuloplasty
• Option for extreme-risk
patients
 Retrograde orFunctionally
antegrade
bicuspid
approach
 Major bleeding in about 20%
 Severity of AS reduced 30-40%
 Immediate symptomatic
True bicuspid
improvement
 No mid- or long-term benefit
Maskatia 2013
 Better outcomes in bicuspid?
Aortic Valve Replacement
Does not address
aortopathy
Standard
techniques apply
Wheat Operation
Aortic valve replacement +
supracoronary ascending aortic
replacement (modified Wheat)
Wheat ▪ JAMA 1964
Nazer ▪ ATS 2010
•Avoids reimplantation of
coronaries
•A good option in BAV stenosis
when aortic root is not dilated
Composite
Valve Graft
• Replacement of valve,
root, and ascending
 Reimplantation of
coronary arteries
 Mechanical, bio-valve,
 Preferred approach by
many
Bioroot
• Option that avoids
use of anticoagulants
 Reimplantation of
coronary arteries
 Used alone, does not
address extensive
aortopathy
 May be combined with
graft to extend repair
Arch
• Replacement of
valve, root,
ascending aorta,
and hemi- or full
arch
 Most comprehensive
repair
 Enhanced risk
 Hypothermic
circulatory arrest
Homograft
• Replacement of valve,
root, and ascending
 Reimplantation of
coronary arteries
 Lifespan somewhat
unpredictable
 Roughly 10 to 12 years
 May be useful with
concomitant infection or
endocarditis
Degenerated Homograft
(replaced BAV--12 years postop)
Degenerated Homograft
(replaced BAV--12 years postop)
Ross
• Pulmonary
autograft
 Infrequently used in
adults
 Risk of late
dilatation as
pulmonary vessel
shares embryonic
source (neural
crest) with proximal
aorta
Minimally Invasive
Right infraaxillary thoracotomy (Ito 2013)
Right anterior thoracotomy (Glauber 2011)
Mini median thoracotomy (Alassar 2013)
• Variety of minimally
invasive approaches for
isolated AVR





Selective use in BAV AS
Results may = standard AVR
Venting heart may be difficult
Mechanical or bio-valves
Urgent conversion possible
3% Gilmanov 2013
2% Glauber 2011
Ito ATS 2013;96:715-7; 25 patients—17 with aortic stenosis, congential BAV in 5 pts; no early deaths
Gilmanov ATS 2013;96:837-43; 182 RA and upper mini matched to conventional AV; 1.6% early death for both; 47% AS
Glauber JTCVS 2011;142:1577-9.
Alassar JCTS 2013; 8:103; 53 of 58 pts have AS; No early death in 58 patients
Minimally Invasive
Approach: isolated AVR
Use in 192 patients
Median EuroScore 5.2%
Stenosis in 90 (47%)
Biovalve in 160 (83%)
Early death in 3 (1.6%)
Conversion to sternotomy in 3
(1.6%)
 Blood transfusion in 31 (16%)
 Stroke in 1 (0.5%)
 Atrial fibrillation 35 (18%)






Right anterior thoracotomy (Glauber 2011)
Glauber JTCVS 2011;142:1577-9. [Italy]
Minimally Invasive
Approaches to isolated AVR
58 patients; 53 with AS (91%)
STS risk score 5.7%
Biovalve used in 57 (98%)
No early death
No stroke
Reoperation for bleeding in 1
patient (2%)
 Mean hospital stay 6 days






Mini median thoracotomy (Alassar 2013) Hamburg, Germany
Alassar JCTS 2013; 8:103; 53 of 58 pts have AS; No early death in 58 patients; Not clear if BAV present in any
patients
J-incision
Minimally Invasive
• J-incision permits less invasive
valve and proximal aortic repair
Acquir ed Car diovascular Disease
Johnston et al
Outcomes of less invasive J-incision appr oach to aor tic valve sur ger y
Douglas R. Johnston, MD,a Fernando A. Atik, MD,a Jeevanantham Rajeswaran, MSc,b
Eugene H. Blackstone, MD,a,b Edward R. Nowicki, MD, MS,a Joseph F. Sabik III, MD,a
Tomislav Mihaljevic, MD,aA. Marc Gillinov, MD,a BruceW. Lytle, MD,a and LarsG. Svensson, MD, PhDa
ACD
8-10 cm incision
CLEVELAND CLINIC
Obj ective: Less invasive approaches to aortic valve surgery are increasingly used; however, few studies have
investigated their impact on outcome. We sought to compare clinical outcomes after these approaches with
full sternotomy using propensity-matching methods.
M ethods: From January 1995 to January 2004, a total of 2689 patients underwent isolated aortic valve surgery,
1193 viaupper J-hemisternotomy and 1496 viafull sternotomy. Becauseof important differencesin patient characteristics between these groups, a propensity score based on 42 variables was used to obtain 832 well-matched
patient pairs (70% of possible cases).
Results: In-hospital mortality was identical for propensity-matched patients, 0.96% (8 in each). Occurrences of
stroke (P> .9), renal failure (P ¼ .8), and myocardial infarction (P ¼ .7) were similar. However, 24-hour mediastinal drainage was a third less after less invasive surgery (median, 250 vs 350 mL; P< .0001), and fewer
patients received transfusions (24% vs 34% ; P < .0001). More patients undergoing less invasive surgery
were extubated in the operating room (12% vs 1.6% ; P< .0001), postoperative forced 1-second expiratory volume was higher (P ¼ .009), and fewer had respiratory failure (P ¼ .01). Early after operation, pain scores were
lower (P< .0001) after less-invasive surgery and postoperative length of stay shorter (P< .0001).
Propensity matched cohort
Propensity matched patients (832)
Death
Stroke
J-incision
Full
8 (1%)
8 (1%)
11 (1%)
11 (1%)
202 (24%)
286 (34%)
Conclusions: Within that portion of the spectrum of isolated aortic valve surgery where propensity matching
was possible, minimally invasive aortic valve surgery had not only cosmetic advantages, but blood product
use, respiratory, pain, and resource utilization advantages over full sternotomy, and no apparent detriments.
Less invasive aortic valve surgery should be considered for most aortic valve operations. (J Thorac Cardiovasc
Surg 2012;144:852-8)
Supplemental material is available online.
Earn CME credits at
http://cme.ctsnetjournals.org
Red blood cell transfusion P<.0001
From the Department of Thoracic and Cardiovascular Surgery,a Heart and Vascular
Institute, and Department of Quantitative Health Sciences,b Research Institute,
Cleveland Clinic, Cleveland, Ohio.
This study was supported in part by the Kenneth Gee and Paula Shaw, PhD, Chair in
Heart Research (Dr Blackstone), the Donna and Ken LewisChair in Cardiothoracic
Surgery and Peter Boyle Research Fund (Tomislav Mihaljevic), and the Judith
Dion Pyle Chair in Heart Valve Research (Dr Gillinov).
Disclosures: Dr Mihaljevic isaconsultant for Edwards Lifesciencesand IntuitiveSurgical and receives speaker fees from Intuitive Surgical. Dr Gillinov is a consultant
to Edward Lifesciences and receives honorari a for speaking from St Jude Medical,
Inc. He has an equity interest in Viacor, Inc.
R i df
bli ti S t 15 2010
i i
i d N 7 2011
t df
In the mid-1990s, less invasive ‘‘ keyhole’’ approaches for
valve operations were pioneered with the intent of reducing
morbidity, postoperative pain, and blood loss, improving
cosmesis, shortening hospital stay, and reducing cost compared with the 50-year-old full sternotomy approach.1-10
Furthermore, it was believed that less spreading of the
incision, not interfering with the diaphragm, and less tissue
dissection might improve outcomes, particularly respiratory
function.7,8 Although clinical studies suggest that some of
these benefits have been realized, there has been no
confirmatory large study or randomized trial.1-10 Because
patients undergoing aortic valve surgery are in general
older and sicker than those undergoing isolated mitral
valve surgery, cosmetic benefits of less invasive aortic
valve surgery may not be as important. Yet potential
improvement in postoperative pain and respiratory
function, particularly in patients with advanced respiratory
disease, and reduced blood loss, transfusion requirement,
and intensive care unit (ICU) and hospital lengths of stay
are of even greater possible benefit in this older population
Johnston JTCVS 2012;144:852; valve dysfunction not clear; < 3% of cases were converted to full sternotomy
US (NIS) Practice Trends for BAV
For AVR+ Aorta
Substantial
Increase
50% get
mechanical
valves
Opotowsky JTCVS 2013;146:339-46
~50,000 patients; for all procedures, use of mechanical valves decreased from 69% to 38% (1998-2009)
Information of type of pathology is not available (mix of AS, AI, normal functioning valves)
Anything
Else?
European Heart Journal (2012) 33, 2451–2496
doi:10.1093/eurheartj/ehs109
ESC/EA CT S GU IDELIN ES
Guidelines on the management of valvular heart
disease (version 2012)
T he Joint Task For ce on t he Managem ent of Valvular Hear t Disease
of t he Eur opean Societ y of Car diology (ESC) and t he Eur opean
A ssociat ion for Car dio-T hor acic Sur ger y (EACT S)
Aut hor s/T ask For ce Mem ber s: Alec Vahanian (Chair per son) (Fr ance) * , Ot t avio Alfier i
(Chair per son) * (It aly), Felicit a Andr eot t i (It aly), Manuel J. A nt unes (Por t ugal ),
Gonzalo Bar ón-Esquivias (Spain), Helm ut Baum gar t ner (Ger m any),
Michael Andr ew Bor ger (Ger m any), T hier r y P. Car r el (Swit zer land), Michele De Bonis
(It aly), A r t ur o Evangelist a (Spain), Volkm ar Falk (Swit zer land), Ber nar d Iung
(Fr ance), Pat r izio Lancellot t i (Belgium ), Luc Pier ar d (Belgium ), Susanna Pr ice (UK),
H ans-Joachim Schäfer s (Ger m any), Ger har d Schuler (Ger m any), Janina St epinska
(Poland), Kar l Swedber g (Sweden), Johanna T akkenber g (T he N et her lands),
U lr ich O t t o Von O ppell (U K), St ephan W indecker (Swit zer land), Jose Luis Zam or ano
(Spain), Mar ian Zem bala (Poland)
ESC Com m it t ee for Pract ice Guidelines (CPG): Jer oen J. Bax (Chair per son) (The N et her lands), H elm ut Baum gar t ner
(Ger m any), Claudio Ceconi (It aly), Ver onica Dean (Fr ance), Chr ist i Deat on (UK), Rober t Fagar d (Belgium ),
Chr ist ian Funck-Br ent ano (Fr ance), David Hasdai (Isr ael ), Ar no Hoes (The N et her lands), Paulus Kir chhof
(Unit ed Kingdom ), Juhani Knuut i (Finland), Philippe Kolh (Belgium ), T her esa McDonagh (UK), Cyr il Moulin (Fr ance),
Bogdan A . Popescu (Rom ania), Željko Reiner (Cr oat ia), Udo Secht em (Ger m any), Per Ant on Sir nes (N or way),
Michal Tender a (Poland), A dam Tor bicki (Poland), A lec Vahanian (Fr ance), St ephan W indecker (Swit zer land)
Docum ent Reviewer s:: Bogdan A . Popescu (ESC CPG Review Coor dinat or ) (Rom ania), Ludwig Von Segesser (EACT S
Review Coor dinat or ) (Swit zer land), Luigi P. Badano (It aly), Mat jaž Bunc (Slovenia), Mar c J. Claeys (Belgium ),
N iksa Dr inkovic (Cr oat ia), Ger asim os Filippat os (Gr eece), Gilber t Habib (Fr ance), A . Piet er Kappet ein (T he N et her lands),
Roland Kassab (Lebanon), Gr egor y Y.H. Lip (UK), N eil Moat (U K), Geor g N ickenig (Ger m any), Cat her ine M. Ot t o (USA ),
John Pepper , (U K), N icolo Piazza (Ger m any), Pet r onella G. Pieper (T he N et her lands), Raphael Rosenhek (A ust r ia),
N alt in Shuka (A lbania), Ehud Schwam m ent hal (Isr ael ), Juer g Schwit t er (Swit zer land), Pilar Tor nos Mas (Spain),
Pedr o T. Tr indade (Swit zer land), T hom as W alt her (Ger m any)
T he disclosur e for m s of t he aut hor s and r eviewer s ar e available on t he ESC websit e www.escar dio.or g/guidelines
Online publish-ahead-of-print 24 August 2012
* Corresponding authors: Alec Vahanian, Service de Cardiologie, Hopital Bichat AP-HP, 46 rue Henri Huchard, 75018 Paris, France. Tel: + 33 1 40 25 67 60; Fax: + 33 1 40 25 67 32.
Email: alec.vahanian@bch.aphp.fr
Ottavio Alfieri, S. Raffaele University Hospital, 20132 Milan, Italy. Tel: + 39 02 26437109; Fax: + 39 02 26437125. Email: ottavio.alfieri@hsr.it
†Other ESC entities having participated in the development of this document :
Associations: European Association of Echocardiography (EAE), European Association of Percutaneous Cardiovascular Interventions (EAPCI), Heart Failure Association (HFA)
Working Groups: Acute Cardiac Care, Cardiovascular Surgery, Valvular Heart Disease, Thrombosis, Grown-up Congenital Heart Disease
Councils: Cardiology Practice, Cardiovascular Imaging
The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the
ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford
University Press, the publisher of the European Heart Journal, and the party authorized to handle such permissions on behalf of the ESC.
Disclaim er . The ESC/EACTSGuidelines represent the views of the ESC and the EACTSand were arrived at after careful consideration of the available evidence at the time they
were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual
responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient and, where appropriate and
necessary, the patient’s guardian or carer. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of
prescription.
& The European Society of Cardiology 2012. All rights reserved. For permissions please email: journals.permissions@oup.com
Vahanian 2012 Eur Heart Journal
Expert Valvular
Guidelines
Relative Contraindication
to TAVR
Conclusions
• BAVs with significant stenosis
need to be replaced
 Repair usually not an option
 Guidelines and Evidencebased decision-making
•
Aortopathy should be
additionally repaired based on
dilation size, pattern and other
factors
 Age
 General health
 TAVR
Conclusions
• Urgent need for bio-markers of
aortic progression
 Biochemical or rheological
• Define (in this heterogeneous
population) individuals with
bicuspid aortopathy in need of
aggressive intervention
• Guidelines and Evidence-based
decision-making
Thank you!
Question
A 45-year old male is referred for surgical evaluation
after a 4.6 cm ascending aortic aneurysm was found.
Cardiac cath demonstrated no significant coronary
artery disease. Echo showed a bicuspid aortic valve
with a valve area of 0.8 cm2. Which is true?
1.Aortic pathology is anticipated to show fibrillin 1
2.AVR alone is appropriate
3.A Bentall procedure should be performed if the root is
dilated
4.Follow-up of this patient is expected to show an aortic
dilatation rate equivalent to patients with tricuspid
aortic valves
Question
35-year old female with normally
functioning BAV, EF 60%, and a root 4.2
cm at the sinus is planning pregnancy
1.Medical management
2.Ascending graft replacement
3.Wheat (AVR+supracoronary ascending)
4.Bio-composite valve graft replacement
5.Valve-sparing root replacement
Question
A 52-year old man with BAV critical AS and moderate AI.
A CT scan reveals a 4.8 cm ascending aortic diameter.
Cardiac cath shows no significant coronary artery
disease. Each of the following is true EXCEPT:
A. If the ascending aorta is not repaired, there is a significant risk
of aortic complication within the next 15 years
B. A composite valve graft replacement may be needed, especially
if the sinuses of Valsalva are dilated
C. A separate aortic valve and ascending graft replacement (Wheat
operation) may be used if the sinuses of Valsalva are not dilated
D. Replacement of the aortic valve alone, and tailoring the native
aortic tissue using aortoplasty should stabilize the ascending
repair such that graft replacement is unnecessary