EXPERT OPINION FROM HEART VALVE SUMMIT 2014
CHICAGO (FRONTLINE MEDICAL NEWS) – Surgical management of leaky bicuspid valves is rapidly evolving from replacement to repair of any purely insufficient bicuspid valve with enough leaflet surface area.
“We’re coming to the point like with mitral valves 20 years ago, that we don’t have to replace every blessed bicuspid valve. We can repair a lot of these valves,” Dr. Joseph Bavaria, vice chief of cardiovascular surgery, University of Pennsylvania, Philadelphia, said.
A valve-sparing root procedure in a patient with bicuspid aortic valve (BAV) disease and aortic insufficiency (AI) provides excellent results, no matter if the aortic root is abnormal or not. Many patients with BAV, however, have leaky valves without a root aneurysm.
Thus, the “great dilemma” facing surgeons now is whether they can continue to justify doing a root procedure, which is a much bigger operation, when the root is normal diameter, Dr. Bavaria said at Heart Valve Summit 2014.
“It may be inappropriate in today’s world to take a normal physiological valve and just take it out and consign someone who’s in their 30s and 40s to a mechanical or bioprosthetic valve for life,” he said in an interview. “That has anticoagulation issues, structural deterioration issues, infection issues.”
The alternative is a valve repair operation, but that’s complicated by the growing understanding that BAV AI has three distinct phenotypic presentations:
• BAV with AI with relatively normal root diameters.
• BAV with AI and relatively normal root diameters, with an ascending aortic aneurysm.
• BAV with AI and root dilation.
“The problem we have is there’s probably a different therapeutic procedure for each of these three presentations,” Dr. Bavaria said.
The goals for any bicuspid repair are to equalize the free margin lengths with plication or resection of the redundant leaflet, reduce the annulus by 10%-15%, and stabilize it with either reimplantation or a subannular technique, and to increase the height of the free margin, if the leaflet belly falls below the annular plane.
In the university’s current surgical management algorithm, patients who have an aortic annulus dilated to 28 mm or more undergo root reimplantation if they have an aneurysmal root or receive external annuloplasty rings plus a valve repair if their aortic annulus is dilated and they have a nonaneurysmal root. The Dacron ring is placed subcoronary and subannular and is generally sized 5-7 mm larger than the desired end-procedural annular diameter, he said.
For patients with a normal aortic annulus (27 mm or less), root reimplantation or remodeling is used for those with an aneurysmal root, while subcommissural annuloplasty is reserved only for those with a normal aortic annulus and a nonaneurysmal root.
Subcommissural annuloplasty had been used for many BAV patients with AI who were candidates for repair, but emerging data over the last 2 years from Dr. Bavaria’s group ( Annals Thor. Surg. 2014;97:1227-34 ) and others show it results in a lot of midterm failures and reoperations, compared with root reimplantation. Some groups continue to use this procedure routinely, but “It doesn’t work,” Dr. Bavaria said.
His team recently compared postoperative outcomes among BAV repairs and the more commonly performed tricuspid repair between 2004 and 2014. Overall, the outcomes were the same between the two groups including mortality, stroke, freedom from AI grade +1, and aortic reoperation for bleeding (P = NS). Notably, all 41 BAV patients required concomitant primary leaflet repair, compared with only 7% of the 99 patients who underwent tricuspid valve repair (P < .01), he said.
Dr. Bavaria reported consultant fees and honoraria from St. Jude Medical and research grants from Edwards Lifesciences and Sorin Group.
