Aortic Valve Disease

• From Diagnosis to Surgical treatment

• Guidelines And Future
ECHOCARDIOGRAPHY – AORTIC STENOSIS
Pdf 9
PDF 10
“The best time to carry out aortic
valve replacement is the
the“The
day
best time
before thetosymptoms
carry out aortic
begin”valve
replacement is the day before the
symptoms begin” day before the
symptoms begin”
“The most common cause of sudden
death in asymptomatic aortic valve
disease is aortic valve replacement”
PDF 22
AORTIC REGURGITATION
NATURAL HISTORY OF AI
 Bicuspid AV and Ascending AA

• BAV is the most common CHD

• Incidence of 1% - 2%
• 119 cases of fatal dissecting aneurysms of the aorta
• 11 cases of BAV (9%)
• Cystic medial necrosis in all cases
• High incidence – causative relationship
(Cir:5,78 Edwards and Edwards)

University of Minnesota
 BAV and Asc. AA

• Hemodynamic factors

• Manifestation of a single genetic defect

• Chromosome 15q

• Mutation on the fibrillin 1 gene

• Autosomal dominant with incomplete penetrance

• Wide variation in the age of onset

• Aortic enlargement – above sinotubular jn.

 BAV ANA Asc. Ao. Aneurysm

• John Burke, 1998, Clinical Cardiology

• Need for long-term Beta Blockers

• Monitoring with echocardiograms

 MANAGEMENT OF
SEVERE AI

• ASYMPTOMATIC PATIENTS
• Echo Follow up – 6 months
• Afterload reducing therapy, Nifedepine and
ACE Is
• Antibiotic Prophylaxis
 SURGICAL TREATMENT (AVR)

• SYMPTOMATIC PTS WITH SEVERE AI

• ASYMPTOMATIC PTS WITH LVEDD >70 MM

LVESD > 55 MM
ESV > 55 ML/M2

• ACUTE AI WITH LVF

• NO BETA BLOCKERS OR IABP

• ACUTE AI WITH IE, ANTIBIOTICS FOR 5-7 DAYS AND THEN AVR AT
HEMODYNAMIC INSTABILITY OR ECHO EVIDENCE OF MITRAL VALVE
DIASTOLIC CLOSURE
 BAV and AsAA:
Clinical Implications
• Echocardiographic follow-up of all first degree
relatives

• Careful monitoring of the aorta of BAV with echo /

CT chest / MRI

• Beta blocker therapy

 Surgical Options

• Marfans with aortic disease

 composite graft

• AV (tricuspid) disease with Asc. AA

 AVR & repair of aneurysm

• AV (bicuspid) with aortic aneurysm?

 BAV and Progression of
Aortic Dilation
• AVR: 14 TAV 13 BAV
• No AVR: 18 pts
• Echo before and after AVR
• Tricuspid no dilation after AVR
• BAV: aortic dilation continued

(Yasuda et al. Cir 2003, 108)

Long-Term Results: AVR for BAV

• Higher mortality for BAV due to SCD and dissections

• Prophylactic replacement even for normal/mildly enlarged aorta

in BAV pts

(Russo et al. Annals Th. Surgery, 2003:1773)

Surgical Options for BAV and
As. AA
Composite valve graft

Or

Separate valve graft?

45 pts between Jan. 1985 – Jan. 1998

• Separate valve graft 27 pts.

• Composite valve graft 18 pts.

• Periop events and late results were compared

(Sundt, Gay et al. Univ. of Washington,

Annals of Th. Surgery, 2000;69:1322.)

 BAV and As. Aortic Aneurysm
Repair Options
Results:
Separate valve and graft:
older (60 + 13 vs 40 + 12)
more AS (48% vs 6%)
less AI (11% vs 72%)
More concomitant CABG (56% vs 6%)
No significant difference in Op. Risk and no known late
complications related to rec. aneurysms
 CONCLUSIONS

• Root replacement with composite valve graft

with low op. risk and is the first choice

• Separate valve and graft repair satisfactory

results and an acceptable option, especially
with Cor. Ostea are not displaced or with
concomitant procedures must be performed.
 Conclusions
• BAV is quite common

• Often leads to an AV disease

• Requires intervention ¾ of the time

• Concomitant aortic wall disease due to increased fragility

 Conclusions
• Careful monitoring

• Beta blockade

• Replace aorta when AVR is required, regardless of aorta size

• Composite graft vs separate will depend upon aortic sinuses

 QuickTime™ and a
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 QuickTime™ and a
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are needed to see this picture.
 QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
 QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.