Saving the Valve During Aortic Root Surgery

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Lars Svensson, MD, PhD:

Hello, I am Lars Svensson. I am the Chief of the Heart, Vascular and Thoracic Institute. In other words, departments of cardiology, vascular surgery and cardiothoracic surgery. I am delighted to have with me today Xiaoying Lou. She was one of our star trainees here. She came from Emory and did our aorta associate specialty training here at the Cleveland Clinic, and was exposed to all the surgery we do on the aorta here. Last year, 1,650 aorta operations. She did a fantastic job, is a great writer, great speaker. She's one of our upcoming stars, and I'm delighted to chat with her about valve-sparing operations, something that we both do a lot of.

So, starting off with that, Xiaoying, what are the reasons that you see for patients showing up for aortic root aneurysms and needing valve-sparing operations?

Xiaoying Lou, MD:

Well, thank you for the introduction. It's a pleasure to be here. I can't believe it's already been almost two years here in practice.

In terms of the valve-sparing operation, we see a multitude of patients who can present and potentially need this operation. A large proportion are people who have a bicuspid aortic valve, they're associated with aneurysms and can be in that root position. In addition, patients who have connective tissue disease can be more prone to certain aneurysms. Then there can be sporadic aneurysms that have just developed in some patients. They found these aneurysms for a separate reason or incidentally on a CT scan or an echo study, and were worked up and then referred to us for consultation to evaluate that particular patient. In addition, patients who have a valve condition, valve regurgitation of the aortic valve or some stenosis, and then they get referred to us for an aneurysm in that setting.

Lars Svensson, MD, PhD:

Yes, excellent. There are some additional patients with aortitis. Aortitis is inflammation of the aorta, often associated with a history of arthritis, particularly polymyalgia rheumatica patients. About 10% go on to develop aneurysms, and about 50% of the patients we find have a history in the family of aneurysms, particularly for aortic root aneurysms. That’s why we see a lot of patients with connective tissue disorders who develop root aneurysms, whether from Marfan syndrome or Ehlers-Danlos or Loeys-Dietz, and those types of patients who have inherited a type of aneurysm.

All right, what are the typical ways that result in patients coming to see you, including symptoms and what patients may notice?

Xiaoying Lou, MD:

Yeah, so I think an overwhelming, a large portion of these patients who have these isolated root aneurysms may not have any symptoms. They come in because there was an incidental CT scan or echo done for some other issue, atrial fibrillation or some other concern or a murmur or something else. They were seen by their primary care doctor or their cardiologist, and then they were referred to see us after this aneurysm was discovered, and then we work it up.

In patients who have symptoms, typically, those are patients who have something else going on with that valve. Aortic root aneurysms are associated with aortic stenosis or aortic regurgitation. In either of those cases, if it gets to more in the moderate severe category, it can cause some symptoms in patients. They can have some dysfunction of their heart, some dilation of their heart, shortness of breath, they can get some chest pain if they have aortic stenosis, and there's just not enough blood that's leaving the heart. There can be a multitude of symptoms, primarily if the valve is also involved with that aneurysm

Lars Svensson, MD, PhD:

As Xiaoying pointed out, a lot are found incidentally. The common symptoms are fatigue or tiredness, level of activity being somewhat limited, occasionally dizziness and occasionally chest pain. Those are typically more associated with aortic valve stenosis than regurgitation, but we see that also in the group of patients.

It's rare that we see the results of big aneurysms. For example, a big aortic arch aneurysm may cause some hoarseness by interfering with the recurrent laryngeal nerve which wraps around the aorta and gets stretched. Typically, big aneurysms don't cause pain if in the aortic root. The descending aorta or abdominal aorta, they more frequently cause pain independently of the chest pain we see related to valve disease.

All right, so what kind of tests do you do for your patients who are coming in for potential valve re-implantation operations?

Xiaoying Lou, MD:

Yeah, at the very minimum, we like to get a gated chest CT. Now, a lot of patients come in and they get an aneurysm that's initially diagnosed on a non-contrast CT scan. Those kind of give a rough idea of what the aneurysm looks like. But because there's no contrast in it, it's hard to delineate the size and dimensions of that aorta. I found that a lot of scans that are done in some other hospitals, from people coming from other centers, are not gated. The cuts of those scans can be a little rough, and it's hard to actually delineate what is artifact and what's truly the aneurysm. Here we really like to get a gated CT scan with thinner cuts of that aorta to be really able to tell what the size is and to be able to compare size. Often these aneurysms may not be at the right size for surgery just yet or meet indications for surgery, but over time they may be.

We just want to be very careful about measuring the same way every time. We use a special program called TeraRecon that is able to give a center line analysis of that particular cut so that we're able to get that cross-section perfect and analyze the size of that aorta and determine that size measurement and growth over time very consistently in that way.

The other thing we absolutely get is an echo study to look at the function of the valve. Really important for valve sparing root operations is the quality of the leaflets and all of those other factors, calcium, all of those things that are found really seen on that echo study, and potentially a transesophageal echo if we need to delineate even a little bit further. We start with those two. Then, if the patient's meeting indications for surgery, obviously we do kind of a full workup. We get additional studies like a heart catheterization to see if any bypasses are needed at the time of surgery, acquire an ultrasound, pulmonary function testing, and then, based on the patient's unique presentation and comorbidities.

Lars Svensson, MD, PhD:

That's a super summary. Pulmonary function tests, echo, cardiac catheterization, if we go ahead with surgery, and the echo helps us decide whether this is potentially a feasible operation. If patients have calcium, as Xiaoying mentioned, then we generally don't recommend re-implantation operations. What are the benefits of having a valve re-implantation versus having a biological or mechanical valve?

Xiaoying Lou, MD:

We choose patients carefully for valve re-implantation, but we're still able to offer this for a lot of patients. But generally in younger patients the decision becomes whether they have a mechanical aortic valve put in, because of their young age. That mechanical valve will last longer and be more durable than a tissue valve, but obviously has the drawback of being on Coumadin, a medicine that thins out your blood every day for your whole life, or doing the valve re-implantation procedure. We can offer durable results with that valve re-implantation procedure. We really save that patient potentially years of being on anticoagulation and helped them provide a very durable result.

I think the latest studies that you published from Dr. Svensson's data for the Cleveland Clinic showed 95% freedom from re-operation in patients who were offered a valve re-implantation procedure. I think it was almost 500 or even more than that number of patients. That was recently published data and that was over 15 years. Someone who's young who comes in and has that kind of longevity, that saves them a long time from being on blood thinners. Even when we try to tell anyone about it, no one really likes to be on a blood thinner if they can help it.

Lars Svensson, MD, PhD:

Okay, great. Yeah, so as Xiaoying just mentioned, it's important to note that the big benefits for young people are that they don't have to be on a blood thinner for their whole lives with the risks of bleeding. Those can have dire consequences. Although the risk of re-operation with a mechanical valve is quite low, there is the risk of infection on the valve or clot forming on the valve. When it comes to the long-term durability of valve re-implantation operations, as Xiaoying mentioned, one of our residents looked up my personal series of just close to now 600 patients, and 95% of the valves were still working 15 years after surgery. There was no difference in patients with connective tissue disorders. The results were actually slightly better in those patients. We haven't lost any patients in that series of 600 patients in total. We are at a much higher number now of valve re-implantations here at the Cleveland Clinic. Xiaoying’s been doing a great job on these valve re-implantation operations.

I will mention also the biological valves. We do use those in older patients, because the older the patient is, the less likely the valve is going to fail over time. That means that people don't have to be on blood thinners. But the downside is that it will fail over time, and then the question becomes, does the person have a re-operation, or does the patient have a TAVR (transcatheter aortic valve replacement)? In other words, a new valve put in through the groin and inside that re-implantation operation. That's pretty rare. Most of the patients, we re-operate when their valves fail. But I'm sure as patients get older and have had multiple operations, we'll be doing more of those kinds of TAVR within aortic root replacements or re-implantations.

All right, so when it comes to patients coming here, any comments on what you do to help patients, particularly when they come from out of state and fly into Cleveland?

Xiaoying Lou, MD:

We try to make it as efficient as possible. I get a lot of the information, a lot of the studiesc and I review those extensively before. The nice thing nowadays is that most of the electronic records talk to each other, so we're able to see follow-up information, prior echoes, prior CT scans for that individual patient and review those in advance of seeing the patient. Then we get a list of the comorbidities, and we have a whole kind of profile about that particular patient before we even see the patient.

I have a great nurse practitioner team. They go through with me about what tests to order so that if you are a patient who comes from out of town, you come here and you have a pretty efficient visit. You're going to meet with cardiology here, because we do this as a heart team approach here at the Cleveland Clinic. You'll also get all your studies done at once, so you'll have a very efficient day. Echo studies, CT scan, if you need updated studies, and any additional studies that you would need the same day.

Then you meet with me, we go over everything and then if you are determined to need surgery, basically the next visit they come to is the surgery date. It’s super efficient and I really think that's something that a lot of patients have remarked to me that come from out of town. They're impressed by how fast that process is, and everything is pretty slick here when everything works that way.

Lars Svensson, MD, PhD:

We have nurse practice managers that manage your case if you like, and so they will help you through the whole process. They will review all the tests that you have with us, and we will then make recommendations as far as further testing. That will then be set up before you come here, and you may very well have a date scheduled for surgery at the same time, if all the tests seem to align with that this is going to be an operation you need, and then give you some idea what the likelihood is that you have a valve re-implantation.

I usually say 95% of patients who have a leaking valve and an aortic root aneurysm with no evidence of calcium, we can keep the valve. Occasionally, we'll find big holes in the leaflets, perforations that mean we cannot re-implant them. We also note that patients who have had a leaking valve for a long time with an enlarged aortic root tend to have more tears, so they're a bit less likely to be able to have a re-implantation operation. That's basically a summary of things. Our nurse practice managers can also help with arranging the limo service we have, pick you up at the airport, and take you back to the airport also.

One of the common groups of patients we see have bicuspid valves. You touched on that earlier, Xiaoying. What's your approach to patients with aortic root aneurysms and bicuspid valves? There's been quite a lot of literature on this somewhat mixed.

Xiaoying Lou, MD:

So they're a different beast. We have to approach them very carefully. Bicuspid valves oftentimes do have a little bit more calcium. The raphe can be kind of calcified, there can be some abnormal commissures as well. The development is different for those particular valves, so it can be hard to know exactly what we're getting into until we look there and actually see the valve leaflets and assess them and everything else. But it's not to say that a bicuspid valve, even with some moderate [aortic insufficiency] on that bicuspid valve that we can't save. We save a lot of those and we have good outcomes with those patients, but they definitely need some closer follow-up.

So it's very much a case-by-case basis, but we've had a good run of really being able to help a lot of these patients who have bicuspid valves. But I think even if we save them, obviously, they still have a bicuspid valve, so we have to be careful when we save them that we feel like we can offer a durable result. Sometimes we can shave a little bit of calcium, fix the raphe, but if you're doing multiple of these fixes together to try to save that valve, that may not be one that's going to have a durable result. That patient may be better off just having their valve replaced.

Lars Svensson, MD, PhD:

Well, that's an excellent summary, Xiaoying. We don't have the ideal operation for patients with bicuspid valves and aortic root aneurysms. We've looked at various approaches, re-implantations, remodelings, various other approaches. What I would say is we don't see a significant difference in worse outcomes with bicuspid valves and re-implantations so far in our data when we last analyzed that. But the trend is suggesting the long-term results may not be as good. We know that from other studies we've done, where we've compared three leaflet valves with bicuspid valve repairs without the root aneurysms. It is an abnormal valve, and it will give in over time. With a re-implantation, it may last, say, 20 years, but there's a big variability in the durability of bicuspid valve re-implantation operations. If there is calcium, as Xiaoying mentioned, then we tend to lean to replacing the valve with a mechanical valve or biological valve. Those are really the two major options.

We don't recommend the Ross procedure in patients with root aneurysms or aortic valve regurgitation because they have a higher failure rate over time. It's a good operation for all young people with aortic valve stenosis. We've got a lot of data to show follow up on that. We do a lot of re-operations on Ross procedures that have failed from all over the country.

All right, any other comments about re-implantation and the approach you take, Xiaoying?

Xiaoying Lou, MD:

One additional piece that, regardless of whether they're bicuspid or tricuspid, I think our threshold is different here, that even if a patient has some degree of aortic insufficiency or leakiness, we still have options to try to fix that valve. I think in your data series, actually about a quarter or even more patients needed some additional cusp repair technique in addition to the valve re-implantation. The valve was re-implanted, but maybe one leaflet was a little longer or one commissure was not really aligned with the other commissure. There's a variety of techniques that Dr. Svensson has pioneered to help try to save those leaflets and repair those leaflets. Being here, it's been fabulous mentorship, but I've really been taught to look at all parts of the aortic root, as you've told us, about the cusps and the leaflets and the annulus and the sinuses and the sinotubular junction. All of those components come into play. I think that's how we can offer a durable result here.

Lars Svensson, MD, PhD:

Yeah, great. Thanks, Xiaoying. One other comment or question, maybe first to Xiaoying, how do you follow your patients and work with a cardiologist when it comes to patients like this?

Xiaoying Lou, MD:

We try to ensure, first of all, during the operation itself, we get an echo study after everything is done, after the patient comes off the bypass machine to try to make sure that it's as perfect as possible. We don't leave the operating room if it's anything more than a little bit of leakiness of that aortic valve because that has been a marker for failure of these procedures long term. First of all, we try to get as perfect a result as we can in the operating room.

While the patient's still in the hospital, we actually get additional echo studies and a CT scan to make sure that all of that repair looks good before you even leave the hospital. I've been putting a lot of these patients on Plavix, if you're doing some extensive repairs, just for a few months, which can maybe help with a little bit of the inflammation that comes with the valve repair itself, and maybe some durability aspects with that as well. Then, typically at three months, we have these patients come back and follow with another echo and CT scan. Serial echoes over time are really indicated, and particularly for patients with bicuspid valves. I think they need more vigilant follow-up.

Lars Svensson, MD, PhD:

Great summary and a couple of points there that Xiaoying mentioned also. It's critical that you go to a place that does a lot of these operations. Last year, we did some 730 aortic root operations. This is an operation that we do a lot of here at the Cleveland Clinic. In fact, we do about 10% of the aortic root operations in the United States and have much better outcomes than the average outcomes based on a paper on the Society of Thoracic Surgeons database. Great outcomes here, and the follow-up is important. As Xiaoying mentioned, we do what I call graduation pictures, so CAT scan and echo before you leave to make sure everything looks good and then follow up long term.

It's uncommon for patients to need another operation, as we mentioned, whether on the aortic valve or downstream from aortic root to ascending aorta replacement, occasionally the aortic arch. In patients who have aortic dissection before we do the operation, that risk is higher. We have some evidence that it's 1.6% long-term of patients, with particularly Marfan's, potentially having an aneurysm or dissection elsewhere. So not related to the ascending aorta, but their descending aorta.

That's just a summary of what we do here. We do some 6,000 heart operations every year here at main campus. We have an excellent team for backup. We've seen most of the problems that occur with these re-implantation operations. We've standardized it, and we've got our modifications that we believe have resulted in the excellent durability long-term in these patients. That really has been important for making sure that the outcomes later are very good in this group of patients.

Thank you very much for listening to Love Your Heart and thank you to Xiaoying for being part of this interview. She's one of our great rising stars. You can contact her or me if you're interested in learning more about the valve re-implantation operation. Phone number is 216.445.4813. Thank you very much.

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