Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) - PowerPoint PPT Presentation

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 BAVs 2. Mechanisms of AR 3. Morphology of BAV aortopathy THEN, HOW TO DO IT: 4. Operative techniques Stanford University CV Surgery

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

BAV Stanford University CV Surgery

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Correct Prolapse: Cusp Free Margin Shortening Stanford University CV Surgery

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

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

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

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

Tirone David-V S mod V-SARR for Bicuspid Aortic Valve (BAV) - PowerPoint PPT Presentation

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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