Bicuspid Aortic Valve and the Aorta

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy and information about diseases and treatment options. Enjoy.

Eric Roselli, MD:

Hi, I'm Eric Roselli, the Chief of Adult Cardiac Surgery, and the director of Aortic Center, and I'm here with one of our greatest staff surgeons.

Xiaoying Lou, MD:

Well, thank you. That's a lot coming from Dr. Roselli. Appreciate the introduction. I'm Xiaoxiao Lou, Xiaoying Lou. I go by Xiaoxiao.

Eric Roselli, MD:

It's been so great to have you as part of the team.

Xiaoying Lou, MD:

Thank you.

Eric Roselli, MD:

You've fit in seamlessly with us and it's been so fun working together and so it's fun for us to have an opportunity to chat to an audience about what we do every day.

Xiaoying Lou, MD:

Yes. Yeah.

Eric Roselli, MD:

We do this in the hallways with the team all the time and sharing it with the audience is a really nice opportunity. So thanks to everybody who's listening.

We thought that we would talk a bit about the interaction between aortic valve and aortic disease, and again, just a high level view. I think it's important to understand that when we talk about the aortic valve, it's not just some flaps in the middle of a pipe somewhere like we think about sort of manmade valves. The aortic valve is a really complex structure and embryologically, it develops in unison with the aorta. The aortic structure is really critical to the way the aortic valve works. As I've been staring at so many thousands of aortic valves over the last years, I think I've gained a better appreciation of how that embryologic development and the subtleties of the way the valve forms, probably has a bigger impact than I think than we ever realized on the later dysfunction of that valve.

It has to open and close a hundred thousand times a day. Over a lifetime it could be like 3 billion cycles of wear and tear. It's been really kind of cool as we have more and more treatment options available that we can appreciate that interaction between the aorta and the aortic valve. I think one of the probably most common things we see is bicuspid aortic valve or what gets lumped is bicuspid aortic valve, which is really a malformed valve.

Xiaoying Lou, MD:

Right. Yeah.

Eric Roselli, MD:

I know that in this place you've gotten a large experience with that in a short period of time.

Xiaoying Lou, MD:

Yeah. Yeah.

Eric Roselli, MD:

Can you share with the audience some of your thoughts about how we need to think about the aorta when a patient is told they have a bicuspid valve that needs to be addressed?

Xiaoying Lou, MD:

Yeah. So the bicuspid valves, I think we hear an incidence about 2 to 3% in the population, but that's really, I think based on people who come here and we actually study their aortic valves and know that they have a diagnosis. I bet the prevalence of the bicuspid valve is a lot higher than that. But patients who have a bicuspid valve, obviously they're born with it. A normal aortic valve is three leaflets and the bicuspid valves can be completely bicuspid or they can have different leaflets that are fused. Based on different fusion patterns of those bicuspid valves, there's different associations with aortas that can also be developed abnormally.

I think the debate is still out, whether it's just because the bicuspid valve and these associated aortopathies that we see, these aneurysms that grow in association with the bicuspid valves or whether it's because of the valve getting stenosed, causing some of these hemodynamic pressure issues in the aorta, that's also causing those aortas to get bigger. Anyone who has a diagnosis of a bicuspid valve, we need to check their aortas as well because they are often associated with aneurysms either at the aortic root level or ascending aneurysms or arch aneurysms that are associated with them. They also have things that can happen inside the heart that may be malformed as well. It's a way to get in the door that there's a lot of other things that we need to be looking at to diagnose that patient and work them up.

Eric Roselli, MD:

Yeah, it's kind of a constellation of problem, isn't it?

Xiaoying Lou, MD:

It is. Yeah, yeah.

Eric Roselli, MD:

And we see it in so many different patterns. It's interesting, certainly the estimate is that at least a third and probably half of people with a bicuspid valve diagnosis are prone to develop an aneurysm. We did a study where we looked at unicuspid valves, another kind of malformed valve, which all really should be lumped into the same space, they also had about the same incidents of aortic aneurysms.

Xiaoying Lou, MD:

Okay. Yeah.

Eric Roselli, MD:

Sometimes we see it involves the root and sometimes it's the ascending aorta. And so there's a lot of complex decision-making, not just about what we do with the valve, but what we do with the aorta, including whether we deal with the root or we extend into the arch. You want to really be facile with your aortic operations when you're doing that. Increasingly, we're repairing a lot of these valves now instead of replacing them when we are there to address maybe the aneurysm or something.

Xiaoying Lou, MD:

Yeah, I've seen a lot of this in training when I did my aortic fellowship here with Dr. Roselli and was able to see a lot of that because not everyone is repairing bicuspid aortic valves, but you obviously built up a huge practice of this. There are different repair techniques, but we do a lot of valve-sparing root replacements here where if that valve does not have a lot of calcium with it or fenestrations or is otherwise damaged and has pretty pliable leaflets, they can be reconstructed in a way where we can save that valve and that offers really good durability for that patient long-term without the need to replace the valve. And no need for anticoagulation if they're a young patient so that they're not getting a mechanical valve in that position. That's been a really good adjunct procedure to a valve-sparing root replacement, for instance, if the aneurysm has been the main issue for that patient.

Eric Roselli, MD:

Yeah, our hope is that the idea of keeping a living valve is going to be better than replacing one.

Xiaoying Lou, MD:

Right.

Eric Roselli, MD:

I think it's important for people to know though, that if you go down that pathway, you still have a bicuspid valve. We want to have sort of a lifelong view of things and so it's important to continue to follow that. Hopefully, some of our patients who are in their twenties or even thirties that need this done, we've maybe reduced the number of operations they'll need in a lifetime.

Xiaoying Lou, MD:

Right.

Eric Roselli, MD:

We have other choices for dealing with it as well. Certainly, the Ross operation is something we've been doing more of. We're going to see better artificial prosthetic valves, both biologic and mechanical. I think one of the things that's important to remind the patients is, although we don't have the perfect options, we have a lot of really good options and we can tailor it to the patients.

Xiaoying Lou, MD:

Yeah.

Eric Roselli, MD:

I think it's important to be at a center that offers all those different options.

Xiaoying Lou, MD:

Yeah.

Eric Roselli, MD:

We're also seeing a lot of people though, asking us now about transcatheter valves.

Xiaoying Lou, MD:

Right.

Eric Roselli, MD:

I think that's totally reasonable in older patients where the risk of that transcatheter valve totally matches the risk of a surgical valve or maybe reduces the risk as compared to a surgical valve. But of course, there's a lot of excitement when people think, "Oh, I can have this taken care of without opening my chest at all." But there's definitely some downsides to that.

Xiaoying Lou, MD:

It's a great option I think, for patients who are in the higher risk category, but really when we come in, and it's always a heart team approach to evaluate a patient for a transcatheter option versus a surgical aortic valve option. But here at the Cleveland Clinic, I think we really favor doing an open surgery on someone who's young and otherwise healthy because the durability of the TAVR valve, we still don't have great durability data and certainly the number of people who need TAVR explants has, I think, increased over the years. We're seeing more of those and sometimes they get infected and when we have to explant those. I think we're seeing a higher threshold of those patients.

The paravalvular leak rate for the TAVR valves is getting a lot better and the pacemaker rates are way better, but they're still there. The difference is that we can't remove all of the calcium in a transcatheter valve and you do that in an open valve. I do think, especially for patients with bicuspid valves, you get in there and see how calcified that is, and I'd want it debrided and have a new valve put in place of it.

Eric Roselli, MD:

It's nice to put a valve in a clean space.

Xiaoying Lou, MD:

Yeah, get it all debrided.

Eric Roselli, MD:

But also if you have some potential risk for aneurysm, TAVR is not going to address that at all, is it?

Xiaoying Lou, MD:

Right. Right. Absolutely.

Eric Roselli, MD:

We've seen some pretty bad problems where people have pushed that technology into that abnormal space.

Xiaoying Lou, MD:

Yep.

Eric Roselli, MD:

I think it's also really important, I think people understand how safely we can do these operations. Everybody's afraid of having an incision in their chest. I get that. Why wouldn't you be? But our outcomes are outstanding. We just presented all of our annual outcomes recently. They're pretty great, aren't they?

Xiaoying Lou, MD:

Yeah. Well, these are the numbers that I cite to the patients, but I think out of all of the aortic operations that we do, and I don't have the valve data, but I have the root replacement data in elective cases, and they're like 0.5% or something like that.Mortality is what we use as the major outcome, obviously-

Eric Roselli, MD:

It's a fraction of a percent-

Xiaoying Lou, MD:

It's tiny. Yeah.

Eric Roselli, MD:

... of dying. But also-

Xiaoying Lou, MD:

Yeah. So obviously we want that to be zero, but I think it's pretty darn amazing for all the sick patients that we see.

Eric Roselli, MD:

Pretty awesome, right?

Xiaoying Lou, MD:

Yeah.

Eric Roselli, MD:

Also though, these patients afterward, they can get back to normal life, right?

Xiaoying Lou, MD:

Right. Yeah.

Eric Roselli, MD:

I have patients that are competitive athletes after they get through all this stuff. I think that's something that people need to appreciate. That's one of the beauties as it's patients talking to patients, and they share their stories and they reassure each other that even though this is a scary ordeal, there's a really good chance you'll get through it safely and get back to a really high quality of life. And so aortic valve disease and aortic disease, which we have a whole bunch of new technology we've been working on, and maybe we can talk about that in another session, is certainly making the operations safer and easier to tolerate, but more importantly, providing people good, high quality lifelong care. We are here to help educate people about that so that patients can make the best decisions for themselves in a precise way with all the options at hand. Thank you for the opportunity to talk today, and we'll see you all soon.

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