Bicuspid Aortic Valve Surgery

Podcast Transcript

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Eric Roselli, MD:

Hi, I'm Eric Roselli. I'm the Chief of Adult Cardiac Surgery here at the Cleveland Clinic and the surgical director of the Aorta Center.

Juan Pablo Umana, MD:

And I'm Juan Umana. I'm an associate staff at Cleveland Clinic main campus and chair of Cardiothoracic Surgery at Cleveland Clinic Florida.

Eric Roselli, MD:

Juan, you and I talk about heart surgery all the time, so this is kind of pretty easy for us I think today.

Juan Pablo Umana, MD:

What we do.

Eric Roselli, MD:

Yeah, it's what we do. The focus today is to talk about aortic valve disease and kind of in our current practice, we've seen some changes over the last really couple of decades with the advent of TAVR. I think it's shifted the focus of the kind of patients that we see even more towards more complex surgery and some of the things we do. Can you comment on that a little bit?

Juan Pablo Umana, MD:

Yeah, absolutely. I totally agree with you. I think we're seeing less and less patients with blocked aortic valves with aortic stenosis, and we've shifted and focus to aortic insufficiency, really, aortic regurgitation, and sure we agree, we're seeing more and more patients with bicuspid aortic valves, which previously for some reason, we hadn't been concentrating on. And despite the fact that we're talking about 1 percent to 2 percent of the population.

Eric Roselli, MD:

That's a lot, isn't it?

Juan Pablo Umana, MD:

That's a lot. 1 percent to 2 percent of the population of the US having bicuspid aortic valves. It's a lot of patients, and a lot of people who can have a potential complication or evolution of their disease to require surgery. So, I think we're seeing more of those patients, not only for replacement of the valve, but more importantly for repair, which is, this is again something you and I talk about all the time. We have to focus on trying to reconstruct and repair as many valves as we can.

I think that is the one thing that's going to make a difference for patients in terms of survival, in terms of quality of life, right?

Eric Roselli, MD:

Yeah. I think the population is younger, the population with this disease is younger, and one of the things I talk about is we call it bicuspid valve. Like you either have a bicuspid or tricuspid and that's it, but it's a lot more complex than just this dichotomy of two different sorts of valves. We probably call it the wrong thing by just calling it bicuspid valve and putting it all in a bucket. Really. It's miraculous how an aortic valve forms. It all happens in the first trimester, and all these things come together. Your ventricle, your aorta, the sub endocardial cushions, all these things are supposed to coalesce and make this beautiful symmetric structure. And yet what we see is in around 2 percent of the population, it doesn't quite form, and they're left with somewhere in the spectrum of bicuspidness. Right?

Juan Pablo Umana, MD:

Not quite three leaflets, but somewhere around two, sometimes two perfect leaflets, other times not so perfect.

Eric Roselli, MD:

Yeah, and it's that balance of the leaflets that we want to try and reconstruct, right?

Juan Pablo Umana, MD:

That's right. And that's the reason why studying these patients and getting the right information before the surgery is so important, why we need to get a good quality echocardiogram, to make sure that we understand what the valve looks like and how it's failing, if it's failing at all. Together with a CAT scan, which then will tell us if there's something else associated with it. Because oftentimes bicuspid aortic valves have a deficiency in collagen, which leads to dilatation of the aorta, either the root right as it comes off of the heart, where the coronaries come out, or beyond that in the tubular portion or the central portion of the ascending aorta, and even the arch, so that all conditions what we need to do and how extensive the surgery needs to be in order to make it more durable. Right?

Eric Roselli, MD:

Yeah, that's interesting. You look at some of the data, it says maybe 35 percent of patients or something like that have this aortopathy or this aneurysm or propensity to develop an aneurysm, but I was just looking at one of the papers we wrote a few years ago about patients with unicuspid aortic valve, 60 percent of them had aneurysm. So, I think it's a lot. It's probably underappreciated, and as we have understood more over the last really couple of decades, Toby Cosgrove started doing valve repairs in the '90s around here. So, we have a lot of experience, but as we've learned more and more about the details of how all that complex anatomy interacts and then developed skills and techniques to repair these valves, I think we've gained a better appreciation for how all those structures work together.

So, let's say we have a patient who has a bicuspid valve and severe regurgitation or leaking of that aortic valve and they're, I don't know, maybe 50 years old. What kind of operation are you thinking about and what sort of discussion are you having with that patient?

Juan Pablo Umana, MD:

I think the first thing is getting all the information and adequate studies. As we just said, if it's a bicuspid aortic valve, again, two perfect fits, one of which may be prolapses and that's causing that severe regurgitation. Actually, there are surgeons who say those valves were made to be repaired, and I think we're getting better at it. We have a tremendous experience with that here. And the conversation I would have with that patient is the first thing we need to do is evaluate that valve intraoperatively, because the last word is always dependent on what we actually see in the operating room. Wouldn't you agree?

Eric Roselli, MD:

Yeah, absolutely.

Juan Pablo Umana, MD:

And once we do that, then we have to take into account several things. One, is how dilated the actual aortic annulus is, and if we have to do something to it.

Eric Roselli, MD:

And the annulus is that space where the ventricle and the aorta come together where the valve sits.

Juan Pablo Umana, MD:

Exactly where they join, yeah. Exactly where they join. And if that is dilated, we have to address it. We have to fix it and do an annuloplasty, which means we have to decrease it in size so that the valve can work properly inside that junction between the aorta and the ventricle. Then there's the leaflets. We have to make sure that the leaflets don't have any calcium, that if they prolapse or one of the two prolapses, we're going to need to probably plicate them to make them come up and come together in the right place. And then of course, there's the dilatation of the aorta or the roots, and when the root is dilated, then our preference, and again, this is something that we've discussed and have come to understand, that when the root is greater than four centimeters, 4.5 centimeters, it's probably best to just replace the root and take that valve and reimplant it within a new aorta, which we use a Dacron tube for. Right?

Eric Roselli, MD:

Yeah. Those grafts are very durable.

Juan Pablo Umana, MD:

Those grafts are extremely durable, and that we know is an operation that has a very low risk of mortality, great results long-term, patients feel well, patients don't need blood thinners. Instead of having a valve that's replaced with a durability that probably in a 50-year-old is going to be, what, 10, 15 years by replacing it, we're extending that probably more beyond 15 to 20, and then there are other possibilities open for that patient.

Eric Roselli, MD:

I'm glad you mentioned the point about making the intraoperative assessment. Again, knowing the history of valve repair around here, there was a time when we would get really aggressive about cleaning up valves and things like that. And what I'll often tell a patient is, I can repair any valve. The question is, should I? And so, I think the quality of the tissue really makes a big difference.

And so sometimes we get lucky on an imaging study, you see a little bit of calcium on there, and when you get in there, it's really only one little spot and a whole bunch of really healthy tissue, and you can still repair it. But I think that's something that we guess around with our imaging, and we can kind of estimate what the chances of repair are, but ultimately, that decision is made intraoperatively about how healthy the tissue is that we're working with.

Juan Pablo Umana, MD:

Yeah. We're about what, 95 percent right when we assess that valve before the operation? With all the imaging we do, would you say that we're right about 90 percent of the time, 95 percent of the time?

Eric Roselli, MD:

Well, if it's clean, looking at all the imaging points towards a repairable valve, I can feel confident to tell someone 95 percent chance I'm going to repair it. However, sometimes I'll see something on an imaging study, and I'll say this one, I'm suspicious of something I'm seeing on the imaging, and I might tell a patient 50 percent, 60 percent, 70 percent, 80 percent chance to repair depending on how severe some of those little subtle changes are.

So, the imaging is fantastic, and with the modern computing software tools, even us surgeons can review all those images really well. It really helps us. So, when we do the repair though, and again, we're still kind of focusing on a discussion, I think around bicuspid valves, it's still a bicuspid valve, isn't it that we leave in those patients?

Juan Pablo Umana, MD:

Yes, yes. That's always a question. That's always a question that comes up when you're sitting with a patient of the family regarding what to do with that valve. But we know that bicuspid valves, when they fail because of stenosis, because of calcium and degeneration, we see those patients in the sixth or seventh decades of life. So, we know those valves can last, and we're not repairing stenotic valves, we're repairing valves that are insufficient. So, although this is a fairly new operation, I'm sure you would agree, it's something that we've been doing probably consistently since the late '90s, early 2000s.

The follow-up is not that extensive just yet, but what we've seen is that durability of a well-repaired bicuspid aortic valve is probably 96 percent at 10 years, probably goes down to about 85 percent of 20.

Eric Roselli, MD:

That's pretty good.

Juan Pablo Umana, MD:

That's pretty good.

Eric Roselli, MD:

That's pretty great.

Juan Pablo Umana, MD:

That's pretty good.

Eric Roselli, MD:

Yeah. Yeah. So, it used to be just kind of a focus on the leaflets, and now we've learned to appreciate the things like you mentioned, the annulus and all the aortic structures, and we have a lower threshold to do a valve sparing root replacement as part of the reconstruction. Right?

Juan Pablo Umana, MD:

As we get better and more efficient at it.

Eric Roselli, MD:

I think that's proven more durable. It's interesting, I replaced a valve on gentleman, it was a bicuspid valve that was stenotic, but his valve, he was on the spectrum of bicuspidness. That was a very symmetric valve when it formed in him. That's the kind of thing we want to achieve when we're creating a repair is symmetry.

Juan Pablo Umana, MD:

Yeah. Thanks a lot, man. It's good. Awesome.

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