What is Valve-Sparing Aortic Root Surgery?

Podcast Transcript

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Eric Roselli, MD:

Hi, everyone. I'm Eric Roselli, the Chief of Adult Cardiac Surgery and the Surgical Director of the Aorta Center at the Cleveland Clinic. And I'm here with one of the newest additions to our staff, Marijan Koprivanac, who is, really, an amazing surgeon already in his own right, who has joined our aortic team, to talk about the topic of aortic root surgery for patients with aortic valve disease. Welcome, Marijan.

Marijan Koprivanac, MD:

Thank you for having me.

Eric Roselli, MD:

Of course. I think one of the questions that comes up, first of all, in this whole, sort of, subject, is what exactly is valve-sparing aortic root surgery? Why is this relevant? Patients with valve disease... tell us a little bit about the root and the valve. What's going on there?

Marijan Koprivanac, MD:

Aortic valve-sparing root replacement is important, kind of, a segment today in addressing the dilation of aortic root aneurysms. It is important in the ways that, for younger patients who have relatively preserved functional valves, we can replace the root by saving the valve and having, basically, restoring the normal anatomy of the patient. Allowing them to have very, basically, normal life durability of that valve, and that should, theoretically, last even for the rest of their lives without having more interventions or having any anticoagulations down the line.

Eric Roselli, MD:

Yeah. I think, again, just a lot of our audience is patients, and I even remember as a young medical student being confused by all this terminology. It's important, I think, to stress the point that the aortic valve isn't just some moving part sitting at the top of your heart, right? It's part and parcel of that first part of the aorta that we call the root. So in order for the aortic valve to function well, there are a whole bunch of different structures that are involved with it. What we call the annulus, or the opening to the heart where the valve sits. The root, that first section of the aorta, really sits inside the heart, doesn't it? I mean, we often have to, kind of, separate muscle off of that root of the aorta. The valve is suspended inside of that first section of the root, so a lot of times people need a new aortic valve because it's stenotic or degenerated or calcified. But a lot of times the primary problem actually involves the root itself. The other components of the valve are, sort of, stretched out. That's the aneurysm that you're talking about, right?

Marijan Koprivanac, MD:

Exactly.

Eric Roselli, MD:

So a more conventional way to handle that root aneurysm is to replace everything, right? In a lot of places that is the way it's handled. Not everybody everywhere does valve-sparing root operation or, what we call, re-implantation, and sometimes that's the right thing to do, right? Those other options are often referred to as a Bentall procedure, right?

Marijan Koprivanac, MD:

Right.

Eric Roselli, MD:

Can you, kind of, tell us a little about that?

Marijan Koprivanac, MD:

Yeah. By Bentall is, kind of, a more traditional way of dealing with this sort of surgery, where you have the aneurysm dilation of your aortic root. It's a little bit simpler because you just replace, pretty much, everything. You replace the aortic valve. You replace the root, the sinuses, all that complex anatomy that you mentioned. Then you, pretty much, just reattach these coronaries to that buttons, those coronary buttons to the root. So it's a little bit simpler, still complex, but simpler, kind of, a procedure. And at the end, you get this prosthetic valve instead of your own valve that you had. If it's mechanical, you need anticoagulation. If it's a biological, it has certain lifespan durability.

Eric Roselli, MD:

Right. And as you were saying earlier, the advantage of one of these valve-sparing operations is you keep that living valve. I hope you're right that it has the potential to last a lifetime.

Marijan Koprivanac, MD:

Correct.

Eric Roselli, MD:

But it's certainly, in the right selected patients where the moving parts still look healthy, our goal is to keep that living valve, hopefully, for a lifetime without anticoagulation, right?

Marijan Koprivanac, MD:

Exactly.

Eric Roselli, MD:

Again, we talk about, sort of, patients in these categories as though they have valve disease, and then they have root disease, or maybe a combination of both. But it's way more complex than that, right? There's a whole spectrum of, kind of, involvement in things. Which kind of patients do you think... let's say, which kind of patient is the ideal patient for one of these valve-sparing root replacements? What we refer to as a re-implantation procedure?

Marijan Koprivanac, MD:

Well, ideal patient would be a younger patient who, pretty much, has preserved his aortic valve. It's, kind of, a functional valve with isolated root dilation. The valve that requires minimal, what we call a, tweaking or repair of the leaflets and, pretty much, just requires replacement of the root itself.

Eric Roselli, MD:

Yeah.

Marijan Koprivanac, MD:

Of the aorta.

Eric Roselli, MD:

Yeah. I've noticed that over the years, as we've gained a better appreciation for this, and we do these operations better, that we seem to lower the threshold of when we do it, right?

Marijan Koprivanac, MD:

Absolutely.

Eric Roselli, MD:

Because if you wait until the aneurysm gets too big, certainly there's the risk that it can rupture, and that's a fatal complication. Of course, we want to avoid that. But, also, if you watch it stretch for too long, it can cause the leaflet, so the moving parts of the valve, to be damaged. And it's a lot harder to save something after it's been pretty beaten up from that process. So what we, kind of, got to do is pick that sweet spot when we think the aneurysm's big enough that it might be dangerous to watch it too long because we worry about it rupturing, but, also, kind of, get to it before the leaflets have been damaged. The cool thing is in a center like ours and other, sort of, centers of excellence with enough experience of these, we can keep the risk really low, right?

Marijan Koprivanac, MD:

Absolutely.

Eric Roselli, MD:

There's pretty good data from the national database that shows that the volume of aortic root surgery that a center does correlates directly with the outcome. When I say outcome, I mean the risk of death, right? With heart surgery, that's always a risk. At our center compared to even other university centers, our mortality rate is one-third of those places. It's pretty cool. Because we have such a huge experience. We do over a thousand thoracic aortic surgeries a year. I think it was 1,063 last year when we showed it the annual report, and 122 of those were these valve reimplantation procedures. We've consistently been doing over a hundred a year, so we can do them quickly and safely. Just as safely as that Bentall operation that you were talking about.

Marijan Koprivanac, MD:

Yeah.

Eric Roselli, MD:

We do, sort of, have a subset of surgeons that do those operations. Is it safe to say that's one of the favorite things that you do?

Marijan Koprivanac, MD:

Absolutely.

Eric Roselli, MD:

Yeah. Although, you like all the aortic surgery, don't you?

Marijan Koprivanac, MD:

Oh, well true, but the skill to repair the valve takes a job.

Eric Roselli, MD:

Yeah. What about if the patient comes to us, and they have a dilated root, and their valve is leaking?

Marijan Koprivanac, MD:

That's a great question. You already mentioned, that there are multiple shades of gray. It's not everything black and white. Of course, if there is a big root, big aneurysm, almost all of the valves are going to be leaking because they're not going to be cohabiting well. But the question is what kind of a leak it is. Would this be, kind of, what we call a central leak, kind of, a symmetric leak, or would this be, maybe, an eccentric leak, which means it's not really just from dilation, maybe it is from a damaged leaflet somewhere? It really depends on how, preoperatively, that leak looks like, and, also, how it looks when we look at it. Then it's our judgment, where our experience of a high volume comes in and tells us where we can repair this valve durably enough.

Eric Roselli, MD:

Right.

Marijan Koprivanac, MD:

To be good enough for a long enough time to make it worthwhile for the patient and safe enough, so it, kind of, varies. If it's dilated and leaking, doesn't mean we cannot fix it. It still depends on these other variables that we have to look at.

Eric Roselli, MD:

Yeah. I think it's been really, kind of, awesome over the last decade and a half as I've seen our valve repair practice grow and our experience with these re-implantation operations grow as we've been able to apply that technique to evermore complex patients. And the imaging has just gotten so good, and our understanding of how that imaging correlates with what we find in the operating room. Sometimes I'll tell a patient, "Hey, 95% chance or better," and maybe even underestimating, "that we're going to save this valve." Then sometimes I'll say, "Look, this one's 50/50. I don't like some of the things I see on either the echo or the CT scan." Then what I tell them sometimes... I don't know if it's arrogant or not, but it's real. I say, "I can repair any valve. The question is not, 'Can I?' it's, 'Should I?'"

Marijan Koprivanac, MD:

Correct.

Eric Roselli, MD:

Right? Because we want to say for a patient, and the patients are very much part of the decision-making process. If a patient wants to avoid anticoagulation, and they know that something needs to be done for that root, which may mean something to the valve, we've got to decide whether that repair is going to be, at least, as durable as one of those biologic valves.

Marijan Koprivanac, MD:

Exactly.

Eric Roselli, MD:

Which average... I don't know. What do you tell your patients you average?

Marijan Koprivanac, MD:

15 years or so. Something like that.

Eric Roselli, MD:

About 15 years. Yeah, I think that's right. So those are the kind of things, the decisions we make based on the imaging and our view in the operating room about whether we can repair it or not. And we have to, kind of, tailor it to the patient, as well. I'll see someone in their 20s, and if it's a woman who is considering pregnancy or something, I might get a little fancier with the repair.

Marijan Koprivanac, MD:

Yeah.

Eric Roselli, MD:

Knowing that it might not be as durable because we have to do a little more to it, but it might make subsequent pregnancies or something easier. Whereas, if I see someone who's in their mid-50s or even 60s... and I've actually done valve reimplantations in patients who were 80 who have a good lifespan and pretty nice looking leaflets, but we, kind of, have to balance all those, sort of, predictions about the future. I think we're just going to keep getting better as we keep working and building teams, and we have more personnel with this kind of expertise.

Eric Roselli, MD:

It's been really fun to work together with you, and you've been just an awesome addition to our team. Looking forward to us working on some research projects to study all these questions more. We're doing some cool stuff with newer imaging techniques to try and help guide us. I think the message for our patients should be if you may be a potential candidate for one of these problems, is to gather the knowledge you need and seek it out from people who are really experts in this field. We're happy, of course, to help you in that process in Cleveland, and we thank Adam and his team at heart-valve-surgery.com for all the wonderful teaching they do. Thanks. And thanks for your time today.

Marijan Koprivanac, MD:

Thank you.

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