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Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR FUNDAMENTALS: 1. Pathoanatomy of different types of

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  1. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  2. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR FUNDAMENTALS: 1. Pathoanatomy of different types of BAVs 2. Mechanisms of AR 3. Morphology of BAV aortopathy THEN, HOW TO DO IT: 4. Operative techniques Stanford University CV Surgery

  3. BAV (26%) vs. TAV (74%) Aortic Valve July 1993 – March 2010 (n= 242) 35 BAV 30 TAV 25 20 15 10 5 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

  4. BAV Stanford University CV Surgery

  5. Sievers’ BAV and UAV Nomenclature System 2 raphés - Type 2 0 raphé - Type 0 1 raphé - Type 1 Main Category: Number of raphes 21(7) 269(88) 14(5) ap lat L - R R - N L - R / R - N N - L 1.subcategory: 13(4) 7(2) 216(71) 45(15) 8(3) 14(5) spatial position Of cusps in Type 0 and raphes in Type 1 and 2 2.subcategory: V F I 6(2) 1(0.3) 79(26) 22(7) 3(1) 6(2) U A N L S 7(2) 5(2) 119(39) 15(5) 3(1) 6(2) C V T U I B(I+S) 1(0.3) 15(5) 7(2) 2(1) 2(1) L O A N No 3(1) 1(0.3) R Stanford University CV Surgery Modified from Sievers, H-H. and Schmidtke, C. JTCVS 2007;133:1226

  6. Sievers’ BAV type for Stanford V-SARR (N=64) 2 raphés - Type 2 0 raphé - Type 0 1 raphé - Type 1 Main Category: Number of raphes 28% 72% 0% 21(7) 269(88) 14(5) ap lat L - R R - N L - R / R - N N - L 1.subcategory: 13(4) 7(2) 216(71) 45(15) 8(3) 14(5) spatial position Of cusps in 5% 12% 0% 16% 2% 65% Type 0 and raphes in Type 1 and 2 2.subcategory: V F I 6(2) 1(0.3) 79(26) 22(7) 3(1) 6(2) U A N L S 7(2) 5(2) 119(39) 15(5) 3(1) 6(2) C V T U I B(I+S) 1(0.3) 15(5) 7(2) 2(1) 2(1) L O A N No 3(1) 1(0.3) R Stanford University CV Surgery Modified from Sievers, H-H. and Schmidtke, C. JTCVS 2007;133:1226

  7. Type 0 - No raphé (7%, “Naturally Perfect” BAV) 28% Lat (4 % ) AP (2 % ) 12% 16% Stanford University CV Surgery

  8. T. David V-SARR for BAV Sievers’ type 0/lat/n Stanford University CV Surgery

  9. Type 1 BAV - Single raphé (88%) 72% L - R (71 % ) R - N (15 % ) N - L (3 % ) 2% 5% 65% Stanford University CV Surgery

  10. T. David V-SARR for BAV Sievers’ type 1/L -R/n Stanford University CV Surgery

  11. T. David V-SARR for BAV Annular Dilatation Stanford University CV Surgery

  12. T. David V-SARR for BAV Annular Dilatation Stanford University CV Surgery

  13. T. David V-SARR for BAV Annular Dilatation Stanford University CV Surgery

  14. T. David V-SARR for BAV Annular Dilatation Stanford University CV Surgery

  15. J Thorac Cardiovasc Surg 135: 901, 2008 N= 64 BAV patients CTA or MRA of thoracic aorta • Aortoventricular junction • Sinuses of Valsalva • Sinotubular junction • Tubular ascending aorta • Proximal to innominate artery • Distal to innominate artery • Proximal to LSCA • Distal to LSCA • Proximal descending aorta Stanford University CV Surgery

  16. Cluster III Cluster I I Cluster II Cluster IV II III IV Stanford University CV Surgery Fazel, S. et al. J Thorac Cardiovasc Surg 135:901-7, 2008

  17. Fazel-Stanford Morphology Clusters BAV-Associated Aortopathy Stanford University CV Surgery Fazel, S. et al. JTCVS 135:901, 2008

  18. T. David V-SARR for BAV Fazel-Stanford Cluster I aortopathy Stanford University CV Surgery

  19. T. David V-SARR for BAV Fazel-Stanford Cluster II aortopathy Stanford University CV Surgery

  20. Fazel-Stanford Morphology Clusters BAV-Associated Aortopathy Transverse Arch Involvement Arch dilated in 73% (types III and IV) Stanford University CV Surgery Fazel, S. et al. J Thorac Cardiovasc Surg 135:901, 2008

  21. Shafie S. Fazel M.D., Ph.D. (1973-2010) Stanford University CV Surgery

  22. T. David V-SARR for BAV Preop 4-D CTA Stanford University CV Surgery

  23. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  24. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  25. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  26. “Peninsula style” partial or total arch replacement Not the same as a “hemiarch” replacement Stanford University CV Surgery

  27. “Peninsula style” partial or total arch replacement Not the same as a “hemiarch” replacement Stanford University CV Surgery

  28. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  29. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Suspensory cord at LCC- RCC commissure NCC Raphé

  30. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  31. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  32. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  33. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  34. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  35. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  36. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Sievers type 0/ap BAV; BOTH coronary ostia are very close to the 2 commissures Stanford University CV Surgery

  37. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  38. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Lower suture line Stanford University CV Surgery

  39. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Lower suture line Stanford University CV Surgery

  40. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Lower suture line Stanford University CV Surgery

  41. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Misconceptions- lower suture line Stanford University CV Surgery

  42. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Lower suture line Cameron D and Vricella L: Op Techs Thorac Cardiovasc Surg 2005 Stanford University CV Surgery

  43. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  44. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  45. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  46. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  47. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  48. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  49. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  50. Correct Prolapse: Cusp Free Margin Shortening Stanford University CV Surgery

  51. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  52. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  53. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  54. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  55. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  56. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  57. Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) Aortopathy and AR Stanford University CV Surgery

  58. T. David V-SARR for BAV Postop TTE Stanford University CV Surgery

  59. T. David V-SARR for BAV Discharge 4-D CTA

  60. Annular reduction and creation of adequate cusp coaptation height Stanford University CV Surgery

  61. T. David V-SARR for BAV Discharge 4-D CTA Stanford University CV Surgery

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