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The evolution of surgery of the Aortic Root From Bentall to valve-sparing procedures

Dimitrios Avgerinos, MD, PhD, FACS, FACC

Assistant Professor of Cardiothoracic Surgery

New York Presbyterian, Weill Cornell Medicine

2nd Athens Cardio-Vascular & Thoracic Symposium

Athens, Nov 7-9, 2019

https://ctsurgery.weillcornell.org

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No relevant disclosures

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Aortic Root Anatomy

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Aortic Root Anatomy

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Aortic Root Anatomy

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Aortic Root Anatomy

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Aortic Root Anatomy

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Aortic Root Imaging - Echo

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Aortic Root Imaging – CT angio

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Indications for surgery in root pathology

• Aneurysm

• Presence of dissection

• Endocarditis with root abscess

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Indications for surgery in root aneurysm

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1. Bicuspid Aortic

Valve

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Bicuspid Aortic Valve (BAV)

• Two functional aortic valve leaflets with two

complete commissures

• Not simply a fusion of two normal cusps

• Incidence: 2-3% of the population, with some

familial clustering

• Associated with coarctation, interrupted aortic

arch, Turner s.

• 3 criteria

o Unequally sized cusps (Larger leaflet is the

"conjoined" leaflet)

o Presence of a central ridge – raphe

o Smooth cusp margins - Excludes tricuspid

valves which fused due to inflammatory

processes (eg, rheumatic fever)

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BAV Physiology

• Normally functioning bicuspid valve

• Abnormal folding and creasing

• Restricted motion

• Turbulent flow

• Prolonged stress leads to valve damage

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BAV Pathology

• Aortic Stenosis

• Aortic Insufficiency

• Bacterial Endocarditis

• Aortic root aneurysm and Dissection

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BAV Pathology

• Aortic Stenosis

o Poorly functioning valves may have

incomplete systolic opening

o Responsible for 80-95 % of aortic

valve disease detected in infancy

• May cause rapid deterioration

• Progression over years is more

common

• Bicuspid valve may be prone to

accelerated aging

• Sclerosis begins in the second decade

of life

• Estimated that 50% of adults with

severe AS have bicuspid valves

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BAV Pathology

• Aortic Insufficiency

o Isolated AI

─ Prolapse of redundant larger cusp

o AI with aortic root dilatation

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BAV Pathology

• Aortic aneurysm and dissection

o Approximately 5% of patients

o Abnormal response to

hemodynamic stress

─ Cystic medial necrosis

similar to Marfan’s

─ Dysfunctional

microfibrillar proteins,

endothelial nitric oxide

synthetase, etc.

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BAV Management

• Surveillance echocardiography

• BP and HR control (ACC/AHA guidelines)

o β-blockers

o ACE inhibitors

• Early surgical referral

o AV repair or replacement if no root aneurysm

o Aortic root replacement if >45-50mm

o TAVR (clinical trial in the US)

• First-degree relative screening

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BAV Surgery – Valve sparing

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BAV Surgery – Valve sparing

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2. Connective Tissue

Disorders

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Connective Tissue Disorders

• Marfan

o Autosomal dominant

o Mutations in fibrillin 1 gene (FBN1)

• Loeys-Dietz

o Autosomal dominant

o Mutations of the transforming GF b-receptor genes (TGFbR1/2)

• Ehlers-Danlos

o Mutations of the COL5A genes

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AORTIC ROOT ANEURYSM

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Marfan Syndrome

• Autosomal dominant

• Mutations in fibrillin 1 gene (FBN1)

• Clinical diagnosis (Ghent criteria)

o Aortic Root Dilatation Z-score ≥ 2 AND

Ectopia Lentis

o Aortic Root Dilatation Z-score ≥ 2 AND

FBN1

o Ectopia lentis AND FBN1 with known Aortic

Root Dilatation

o Ectopia lentis AND Family History of Marfan

o Aortic Root Dilatation Z-score ≥ 2 + Family

History of Marfan

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Marfan Syndrome

• Long arms, legs and fingers

• Tall and thin body type

• Scoliosis

• Ectopia lentis

• Pectus excavatum or carinatum

• Flexible joints

• Flat feet

• Crowded teeth

• Stretch marks on the skin that are not related to weight gain or

loss

• Aortic root aneurysm

• MR

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Marfan Syndrome – Aortic root

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Loeys-Dietz syndrome

• Autosomal dominant

• Mutations of the transforming GF b-

receptor genes (TGFbR1/2)

• Clinical signs

o Widely-spaced eyes (hypertelorism)

o White of the eye looks blue or gray

o Wide or split uvula

o Cleft palate

o Instability or malformation of the

spine in the neck

o Aortic aneurysm or dissection

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Ehlers-Danlos syndrome

• Mutations of the COL5A genes

• Clinical signs

o Joint hypermobility affecting both large (elbows, knees) and small (fingers, toes) joints

o Frequent joint dislocations and subluxations

o Soft, smooth skin that may be slightly elastic and bruises easily

o Chronic musculoskeletal pain

o Early-onset osteoarthritis and Osteoporosis

o GI issues: dysmotility, bloating, nausea, vomiting, heartburn, constipation, or hiatal hernia

o mitral valve prolapse or aortic root dilatation

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3. Aortic Dissection

(Stanford Type A)

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Type A Dissection

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Surgical principles in Type A dissection

• General

o Excision of the intimal tear

o Ascending aorta replacement

o Aortic valve re-suspension

o Hemi-arch or total arch

reconstruction (if necessary)

o Treatment of aortic root

pathology (if necessary)

• Aortic root surgery

o Aortic valve and root

replacement

o Valve-sparing aortic root

replacement

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Surgical principles in Type A dissection

• Criteria for aortic root surgery

o Aortic root aneurysm >4.5cm

o Extensive tissue destruction

o Connective tissue disease

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Aortic Root repair

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Aortic Root repair

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Aortic Root replacement

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Types of Surgery of

the Aortic Root

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Bentall Procedure (the original)

• Hugh Bentall 1968

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Bentall Procedure (the original)

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Cabrol Procedure

• Cabrol 1978

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Bentall Procedure (modified)

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AVR conduit with tissue valve

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Aortic Root Valve-sparing operations

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Aortic Root Valve-sparing operations

• Criteria

o Young pt

o Acceptable surgical risk

o Good coaptation of valve leaflets

o No concomitant procedures

o Connective tissue (Marfan, etc)

o Dissection?

o BAV only in experienced hands

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Dacron Graft with Sinuses

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Valve-sparing (re-implantation - David)

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David procedure

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Valve-sparing (re-implantation - David)

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Valve-sparing (remodeling) - Yacoub

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Valve-sparing (remodeling) - Yacoub

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Left coronary button re-implantation

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Objective

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Methods

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Results

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Results

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Results

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Results

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Results

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Results

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Results

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Results

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Results

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Conclusions

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Which valve to chose?

Mechanical Tissue Valve-sparing

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