SHA24/028001

Bicuspid Valve Repair

In Adolecents and Young Adults Rakan I. Nazer MD, FRCSCa Assistant professor and Consultant Cardiac Surgeon Department of Cardiac Science King Fahad Cardiac Center King Saud University

• Bicuspid aortic valve (BAV) has an estimated incidence of 1–2% in the general population.

• 15–20% of patients with BAV present as young and middle-aged adults with important aortic regurgitation (AR).

• The residual 15–20% present later in life with aortic stenosis.

• A significant proportion of patients with bicuspid valves have associated important aortic dilation posing a risk of aortic dissection.

Congenitally bicuspid aortic valves: a surgical pathology study of 542 cases (1991 through 1996) and a literaturereview of 2,715 additional cases. Myo clin proc. 1999 Jan;74(1):14-26.

Should we repair BAV in adolescents and young adults?

Yes, but………

Mechanical Valves Tissue Valves Bioprosthetic Porcine Pericardial Biological: Aortic homograft Pulmonary autograft Porcine root

Björk-Shiley Hancock p value Any valve-related complication Systemic embolism Bleeding Valve thrombosis Endocarditis Perivalvular regurgitation Reoperation Primary valve failure

65±4% 18±4% 51±4% 2±1% 7±2% 8±2% 10±3% 0±0%

66±5% 18±4% 30±4% 1±1% 15±5% 2±1% 29±5% 23±5%

0.26 0.66 0.0001 0.33 0.45 0.09 0.004 0.0001

Mechanical valves are durable but require lifelong anticoagulation Tissue valves do not require anticoagulation but they are not as durable

BAV Repair VS. Mechanical AVR: are they in competition?

The Yale Mechanical AVR Experience: •242 AVR patients 1995-2011.

•Mean age 56 years (17-86 yrs).

•Mean follow-up of 5 years.

10 yr: 93.6% ± 2.4%

10 yrs: 97.1% ± 1.6%

10 yrs: 94.1% ± 1.9%

Mechanical AVR is a GREAT option for young adults with BAV disease‌..who are OK with life long warfarin

What about tAVR vs. BAV repair!

The answer depends of AGE at the time of repair/replacement

AGE

Is BAV repair better than tAVR

< 40 years

Likely

40 â&#x20AC;&#x201C; 60 years

Similar

> 60 years

Not

(Ashikhmina et al. J Thorac Cardiovasc Surg 2010;139:1395-401)

Who are the candidates for BAV repair

1.Palotlogy: BAV regurgitation only ( failure with BAV stenosis > Ross operation) No cusp calcification No cusp thickening Good cusp mobility

2. Preference for no / contraindication for warfarin.

3. Pathophysiology of BAV regurgitation: Pathology specific repair

“El Khoury” Repair-Oriented Classification

Principles of BAV repair •Restore coaptation margin ( 8-10mm) •Restore leaflet mobility.

•Stabilize the annulus.

•No more than mild AI at the end of the procedure.

(A) Schematic drawing of the aortic root with a calliper introduced to measure the height difference between aortic insertion and free margin ("effective height")

(Circulation. 2006;114[suppl I]:I-610窶的-616.)

David Stich

(J Card Surg 2007;22:473-479)

Standard Techniques: •Leaflet plication •Subcommissural annuloplasty •Reinforcement of the leaflet free edge •STJ plication •Root replacement

• 173 BAV patient with AI • Divided into 3 groups:  Isolated BAV repair n=57  BAV repair + supra-commissural graft n=38  BAV repair + root remodeling n=78

5 yrs freedom from â&#x2030;Ľ 2+ AI 95.5% 92.1% 91%

Fig 3 Kaplan-Meier analysis of freedom from aortic regurgitation of II or greater in the three groups: AVR+asc (dashed line) = separate aortic valve repair plus supracommissural aortic replacement; AVR (solid line) = isolated aortic valve repair....

The Annals of Thoracic Surgery Volume 83, Issue 2 2007 S740 - S745

5 yrs freedom re-operation 97% 94% 53.3%

Fig 4 Kaplan-Meier analysis of freedom from aortic valve replacement in the three groups: AVR+asc (dashed line) = separate aortic valve repair plus supracommissural aortic replacement; AVR (solid line) = isolated aortic valve repair. (Dotted line...

The Annals of Thoracic Surgery Volume 83, Issue 2 2007 S740 - S745

â&#x20AC;˘ BAV repair vs. â&#x20AC;˘ BAV repair with re-implantation root replacement

Freedom from re-operation

Freedom from > 2+ AI

%

In Summary •BAV repair is an option for  Young adults with BAV regurgitation  Who do not want warfarin  Who can get 10 yr freedom from reoperation better than tissue prosthesis •Pathology oriented repair for BAV •BAV repair with re-implantation gives the best results