Hi Giacomo, I would not apply the index approach to that situation. With 187cm he is of relatively normal height. His obesity does not reduce his risk for aortic dissection/ruptur. With bicuspid disease I would vote for surgery in this patient. I would have recommended surgery with an aortic diameter of more than 4,5 cm (see 2010 Guidelines Hiratzka at el.) in this situation. Best greetings from Hannover. Andreas

Do you recommend a Bental in him or an aortic valve replacement and ascending aorta replacement as the annulus is not dilated ? we have done some cases this way and reinforce the proximal suture line with a strip of felt

Dr chandrashekar Bangalore India

Dear,

In patients with congenital bicuspid valve, the connective tissue of the ascending aorta is affected. With such dilation, a Bentall should be considered.

W. Mistiaen, Antwerp

I agree that replacement of ascending aorta and aortic root is indicated for ascending aortic aneurysm in patients with bicuspid valve once more than 5 cm. If you operate for valve reasons such as aortic stenosis I replace ascending if >4.5 cm. I feel pretty strongly that BAV associated aneurysm are related to yet undefined connective tissue disorder so a full root replacement with Bentall is generally required in addition to hemiarch under deep hypothermic circulatory arrest. That will ensure removal of all "diseased" tissue. This is particularly relevant in "young" patients.

Regards

Arnar Geirsson

I agree with the above comments in terms of need for aortic rot and ascending replacement. On the other hand, if there is someone with experience in valve sparing surgery (ie David reimplantation procedure) this is a very good option if the leaflets are still relatively preserved. You are then not exposing the patient to lifelong treatment with Warfarin. He may get 10-15 years from his native valve and then the reop is relatively straightforward and he can get a tissue valve.

Dear Giacomo;

The diameters are given for the operation endication (Galicia-Toropenell et al. Cir Ciruj - 2010). Furthermore, most of the experts suggests surgery for these situations. Such these cases, aortic tissue is usually thin and fragile. Yakut's flanged Bentall technique (Yakut C. A new modified Bentall procedure: the flanged technique. Ann Thorac Surg 2001;71:2050-2052) is more appropriate to get comfortable suturing line and bleeding control according to our experience.

Kind Regards

Oguz KARAHAN

Dear Giacomo,

There is a few questions.

First of all I do agree with indication for the surgery.Replacement of the ascending aorta is indicated because of diameter.If there is dilatation of the arch,I would prefer the hemiarch with antegrade perfusion of the brain via right brachial artery .Another question is the valve.Patient with BSA 2,45 is very risky for the Patient Prothesis Mismatch.In my opinion the most important is the annulus.Small prothesis even mechanical can finaly have the same or almost same gradient .And patient will be on warfarin.

I agree that the bicuspid aortic valve is conected with a afectetd tisue.Cogenital bicuspid valve.

Aortic valve sparing operation is the best option but your patient has a stenosis/peak gr, 23/ .

Try the think about op. sec. Wheat /with resection of the nonkoronary sinus,replacement of the ascending aorta and hemiarch if needed.Save his aortic valve and there will be no warfarin needed.

Dear Giacomo,

I personally operated 3 patients for aortic dissection with an ascending aorta diameters < 4.5 mm and all affected by hypertension. I agree with most of the colleagues that the best solution for your patients is a Bentall procedure

Hi Giacomo, the root should be stabilized or replaced in this young patient. We usually try to perfom a valve sparing operation in this age, even in BAV patients unless they do not want to come back for surgery and have no problem taking warfarin for a mechanical valved conduit. In our experience most patients between 50 and 60 choose a biological valve if replacement would be necessary. Because a valve sparing operation in our opinion will have a similar long term outcome than a biological replacement even in BAV patients, our first approach would be a David procedure. Since your patient has a peak gradient of 24mmHg, reconstruction might have to involve extensive leaflet repair and/or decalcification. Because this aggressive reconstruction approach might have a worse long term outcome in BAV patients than a biological Bentall we would usually replace the valve with a Bentall procedure in this situation. Best regards, Andreas

No doubt, surgery !

At 54 years this patient is a candidate for a Ross procedure plus ascending aorta replacement. No worries about PPM or extensive leaflet repair or decalcification with this approach.

Best regards,

Ivan Aleksic

A lot of surgery, but definitely an option. Should be done by a skilled surgeon in an experienced center.

Thank you all for the comments so far. My question was little provocative and I think that we had a very good discussion.

I want to go further in discussion with the followings:

- in case of a valve sparing procedure, how long the native valve will last? I am wondering about the complex pathophysiology of the ventriculo-arterial coupling in BAV: embedding the native valve in a rigid structure will lead to an "accelerated" degeneration? Would the patient come back very soon (namely 2-3 years) with heavy calcified aortic valve?

- what about an ascending aorta replacement as sole procedure through a ministernotomy (2nd intercostal space)? It should leave some "room" for future sternal reentry in order to perform the "definitive" surgery (Bentall procedure).

- in case of direct Bentall procedure (with mechanical valve), do you think that the risks related to projected 25-30 years of warfarin therapy are higher than two surgery?

- Is the option "BioBentall (self-assembled conduit with stented aortic valve)" + transcatheter aortic valve replacement for eventual valve degeneration suitable? Which is the cut-off age that you recommend for this option?

Thank you all againg.

Giacomo Bianchi

Dear,

I will try to respond point-by-point.

The progress of the valve disease is one of the challenging issues: much depends on the degree of the present calcification (if it is present): the higher the current calcium score, the higher the risk for speedy progress of the valve disease and hence need for valve replacement. A CT with calculation of the calcium score can be useful in this respect.

A ministernotomy might - provided it is technically possible - leave room for a second procedure in the future. It mainly depends on the technical expertise of the surgeon and on the anatomy of the patient.

With currently available surgical techniques and mode of peri and postoperative care, the continuous risk for TE might approach the risk of two operations. A self management of INR further reduces the risk of TE and bleeding events, if the patient is capable to handle this issue and the device is available (see the GELIA study).

For a patient of 54 years, a "bio-bentall" will certainly will lead to structural valve degeneration in less than 10 years. A future Valve-in-Valve TAVI might be a solution, provided it is technically possible (which cannot be predicted for now). Moreover, the burden put on the left ventricle by a degenerated valve can increase the risk for a second procedure.

Last but not least, some will debate the ethical issues of a ViV-TAVI.

Sincerely

Wilhelm P. Mistiaen

Do a bental and tell him to loose weight

The ascending Aorta is far more dilated than the limit stated when a bicuspid Aortic valve is present. The replacement of the ascending Aorta is mandatory; if there not more than mild valve insufficiency the surgeon can try a sparing valve operation..I think as the anulus is not dilated; anyway the replacement of the ascending Aorta is needed in very short time.

Bentall + hemiarch.

BAV and ascending aortopathy are genetcally linked pathologies. Whenever valve or aorta or both arise surgical awareness, I prefer to treat them both. Otherwise, remaining pathology will make a lots of problems, some of them very serious (e.g. dissection). Anomalous coronary take-off (RCA) are very common with BAV, therfore, MSCT seems very reasonable in preoperative planning.

Ross could not reach the arch and why should we complicate?

BAV would not stand reconstructive efforts since each and every BAV is genetically diseased!

You really do believe in TAVI?

How many cardiac surgeons would accept the second surgey for themselves?

Denton Cooley: "Learn, simplify and apply."

Hi Mladen..why hemiarch?

I agree with Dr. Kocica, embryologically the aortic valve and the ascending aorta have the same origin and therefore it is rather likely that a problem with one of them is linked to the other. Therefore I would also do a Bentall with an open distal anastomosis another option is a Ross procedure with an open distal anastomosis, in case that the patient does not want to take coumadin. Nevertheless this is a rather challenging procedure and depends on the experience of the surgeon.

I would not go for a David in such a patient due to the bicuspid valve. Eventhough (at least to my knowledge) there is no evidence against it.

Does anybody have move experience with David procedures BAV patients (long term results?)

In this stage I would have thought a Bentall with a biovalsalva graft and leaving the option for a TAVI in the future

Unfortunately I am disagree with many of surgeons for this patient. This patient should be followed by radiological measurements of the aorta. Because its diameter is 52 mm for now, and transaortic gradient is not too much. At first we should follow him for 4-6 months to access enlargement rate of its diameter. During this period we should give beta-blockers to control hypertension. If aortic diameter exceeds 55mm, then we should operate him. I would prefer a valve-sparing ascending aortic replacement with ministernotomy at first. Because, its not so easy to use routinely warfarin. Bicuspid aorta is a congenital defect, and if the patient could be able to live till this age without any symptoms, he can be easily managed with drugs (beta-blockers etc) for many years without need for a second surgery. If he needs a second surgery for aortic valve, then we can perform it easily (due to ministernotomy). In my opinion TAVI, hemiarch replacement, or bentall is far far away for this patient.

I desagrre that this case shoul be decide by surgeon. There is no indication of surgery in this moment based only in the aortic diameter. The patient can be many years asymptomatic with control of the hypertension and followed by images methods before to be submited to surgery.

Dear Hafil, because:

Shafie S. Fazel, Hari R. Mallidi, Richard S. Lee, Michael P. Sheehan, David Liang, Dominik Fleischman, Robert Herfkens, R. Scott Mitchell and D. Craig Miller.

The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch.

J Thorac Cardiovasc Surg 2008;135:901-907.

As for the aortic size debate - YALE UC has launched a sophisticated invidualized calculator defining the threshold diameter of ascending aorta (in cm) that needs replacement, taking into account patients metrics (hight, weight), age and underlaying aortic pathology (free to download at: www.mpoullis.net/aodvd1/when/Page.xls).

According to this calculator - threshold replacement diameter of ascending aorta, in this particular patient is 4.4cm! If we rely on nomogram, cross-matching only BSA and Ao diameter - this patient do have a low risk (up to 4%/y) to dissect, but, as nicely stated by Donald D. Glower in JACC Vol. 58, No. 6, 2011 Editorial: "Size Alone Is Not Enough"! And it is not, indeed!

Surgical community has clearly exposed state-of-the-art in this field (including BAV plasty) at: http://webcast.aats.org/2012-Aortic-Symposium/

BAV and ascending (to transferse arch) aortopathy was also addressed by special issue of Current Problems in Cardiology (long ago) - and in a real world - we did have a lots of such patients in whom "hesitation" has ended up in emergent surgery for acute aortic dissection! That is the worst possible scenario for such people (the youngest patient with such pathology we recently operated on was 12 yo who dissected ascending aorta and developed a life threatening tamponade)!!! Therefore, its far most easier and safer to perform Bentall and hemiarch electively, than to face a myriad of acute aortic dissection modalities!!! If OAT is the most important concern - no problem - BioBentall (in absence of homografts) is quite feasible solution.

I'd like not to be missundestood - I confess my fear from the acute dissections - mostly because I have done more than 150 of them, enough to call them "Tears for Fears"! Someone said: "If we can explain something simply - we do not understand it". I simply do think that we (so far) do not have ANY more reliable strategy to deal with genetically altered, dissection prone aortic wall - but to replace it with graft material! In a future - we'll see. Genetics is miracle, but surgery is still reality:-)

Thanks Dr. Mladen you said it well & your track records are outstanding. Congratulation. By the way I spent several months in Novi Sad Hospital (1987) with the local cardiothoracic surgical team there. It was an exchange fellow program.

Dear Dr Abdulgani,

I am glad to hear that you've spent some time at Novi Sad Hospital. Meanwhile, a lots of things were changed, both in cardiovascular pathology we're dealing with, and cardiac surgical technology. New generations have come and naturally, new ideas. I am sure that exchaning experience with colleagues worldwide was, at least, one of many reasons we're thinking better today. So let's keep this track.

Sure will Dr. Mladen Kocica, I will keep in track. When I was in Novi Sad (1987-1988) the chief surgeon was Dr. Ninoslav Radovanovic.

Prof. N. Radovanovic is still active "lion". I know him very well. He made a lots of good cardiac surgeons during his career, and with no doubt, your time spent with them is not in vain.

Please send my regards & I would appreciate if you can send me his contact address, so I may reconnect...

I think we do not really know the definite answer if a bicuspid valve should change our managment stategy. Also the literatur is not clear and lately different groups have pointed out that "size is not all".

For this particular patient I would first suggest to crucially verify the diameters, as there is a large practice variance of measurement techniques regardless of the imaging method. Depending on the result, I would then probably treat the hypertension and review the diameters in about 6 months, as suggested by Kaan Kaya above.

I think that surgery is a very aggressive treatment in this case. I think that use only exact number or formula for suggest surgical treatment is not ideal. Afraid of acute dissection of the aorta is correct, but to antecipate the surgery can be not better than the control of hypertension and follow the diameter of aorta with image methods. As I wrote above, this patient can be asymptomatic during years with rigorous clinical control.

I absolutely agree with our colleagues Fratz and Jacob. Control of hypertension as well as weight reduction could be adequate at the moment. Obviously this patient require careful surveillance of aortic diameters, by means of echo and/or CT. If there are signs of diameter augmentation with or without clinical signs or symptoms, refer the patient to cardiac surgery department .

May I add to Castorino´s comment that Cardiovascular Magnetic Resonance is the method we would prefer.

I absolutely agree. I forget this.

Challenging case. Several questions:

1. What was the reason firsthand for patient to attend OPC? (chest pain, dyspnea...)

2. If asymptomatic, how was AATA detected and measured? CTscan, NMR, Echo...

3. Is he on optimal medical therapy for his HT? Also, is he compliant with this?

4. If both, you & the patient, are already talking surgery that means he already has some uncertainty about his disease, which in turn, might prompt you to get down to your hands. You're right that, given his BSA, spontaneous risk is around 2%/year, but in terms of the height index (h= 11,3) an indication for surgical repair is sustained. You could try to repair his valve (no calcium, no regurg) and replace ascending aorta. If you feel a composite graft is more likely to occur, I would rather wait & see for 3-6 months, unless his clinical status tells you otherwise.

Dear Mr Bianchi,

I agree with Mr Carlos Garcia-Montero:

First some more details need to be sorted. A diameter of the ascending aorta above 5 cm needs definitly observation and treatment even for this patient. I agree, an important question is: Did the patient visit a mediacal unit because of symptoms? This might guide the direction of treatment.

At the moment we observe a similar case: A 52 yrs old male, 184 cm 110kg. Mild and therefore treated hypertension. No other risk factors. Asymptomatic. AAA discovered in a routine check-up 6-7 years ago. At that time 4.7 cm in diameter. Slowly progression of the diameter. Now 4.9/5.0 cm. Aortic valve competent. Our heart team decided no surgery at the moment, but especially because the patient don`t want surgery at that stage. (Cardiac surgeons voted more pro surgery) Follow-up of the patient is every 3-4 months.....

The patient has to be operated in short time.