Saturday, January 31, 2015
Friday, January 30, 2015
Thursday, January 29, 2015
Wednesday, January 28, 2015
With regard to the tissue valves, there is growing evidence that a TAVR inside a tissue valve is a very realistic and safe option in the future. New data suggests that you do not decrease the size of the valve with the TAVR valve in valve, and can put multiple TAVRs inside valves over time as needed. This is all preliminary work but the evidence is mounting.
Tuesday, January 27, 2015
Sunday, January 25, 2015
Saturday, January 24, 2015
The Modified or "Button" Bentall is a relatively complex surgical procedure wherein the aortic root is replaced with a graft. This necessitates removing the coronary arteries and re-atttaching them to the aortic graft. Complications can arise particulalry at the sites where the coronary arteries are sewn into the graft, known as the coronary anastamoses. However, this study notes that the incidence of such complications is extremely low.
Ann Thorac Surg. 2003 Jun;75(6):1797-801; discussion 1802. Fate of coronary ostial anastomoses after the modified Bentall procedure. Milano AD1, Pratali S, Mecozzi G, Boraschi P, Braccini G, Magagnini E, Bortolotti U.
CONCLUSIONS: The modified Bentall operation is associated with an extremely low incidence of anastomotic complications particularly at the coronary ostia. More extensive use of new imaging techniques is desirable to assess the true incidence of such complications in patients receiving a composite aortic conduit.
Friday, January 23, 2015
Designed for outstanding performance in all three areas of hemodynamics, durability and implantability, the Trifecta valve demonstrates our passion for putting more control into the hands of physicians.
When the Goal Is Hemodynamics Created exclusively for the aortic position, the Trifecta valve delivers larger EOAs, resulting in single-digit pressure gradients.1 The Trifecta valve is designed to mimic the flow of a natural, healthy heart valve and offers excellent hemodynamic performance, which may provide patients with an improved quality of life.
Thursday, January 22, 2015
Patients who have undergone valve replacement are not cured but still have serious heart disease. Patients have exchanged native valve disease for prosthetic valve disease and must be followed with the same care as those with native valve disease.
Reoperation after bioprosthetic aortic valve replacement (AVR). The freedom from reoperation was determined for patients according to the age at initial AVR. These patients did not receive concomitant mitral valve replacement. A, 294 reoperations for the 3152 patients who underwent bioprosthetic AVR. B, 46 reoperations for the 2158 patients who underwent bioprosthetic AVR with contemporary, stented bioprostheses.
Wednesday, January 21, 2015
Tuesday, January 20, 2015
One of the main observations of this study was that reoperation following bioprosthestic valve replacement is influenced by patient age. Fifteen-year freedom from reoperation was 78% following AVR and 62% following MVR in patients more than 60 years of age.
A tissue valve seems like the only way to go for me at age 66.
Monday, January 19, 2015
Sunday, January 18, 2015
Saturday, January 17, 2015
1. During my surgery, will Dr. Wheatley be performing a "button" Bentall procedure or using some other technique to re-implant the coronary arteries?
A. If the coronaries need to be reimplanted, they are done with the button technique. If your aneurysm does not involve the sinus segment (where the coronaries are located) he’ll be able to replace the aorta above the coronaries – negating the need to reimplant. This final decision is made at the time of surgery.
2. Can you outline the surgical steps during my procedure once my heart is exposed? Since I agree with Dr. Wheatley's recommendation to select a St. Jude Trifecta bio prosthesis, is the valve sized first then sewn into the Dacron ascending aorta graft before being sewn into the aortic annulus all during my time on the pump? Or do these valves come in different sizes already sewn into a conduit?
A. You’ve done some good homework. This is an excellent question. Currently a “biologic composite graft” does not exist. This is a device where the valve is pre-sewn into the aortic conduit. The answer to this question depends upon the extent of the repair. Regardless of the method, the aorta is first transected (cut open) to expose the aortic valve. The damaged aortic valve is removed and then sized at this time. If the aortic root (sinus segment) is enlarged enough necessitating replacement, then this is done with a composite graft. Dr. Wheatley will sew the valve into the Dacron aortic conduit (replacement aorta) and then implant this unit into the aortic root and then reimplant the coronary buttons as in question #1. If the sinus segment is not dilated, then the valve will be sewn in the aortic annulus (into the heart) first, followed by replacement of the ascending aorta. There are three general techniques used to complete this procedure – revolving around the extent of aortic root involvement – Full root (with a composite graft), Wheat procedure, AVR/ascending repair with retention if the native sinus segment.
3. Can you estimate the total time on the pump and total time in the OR for me? I know I asked this of Dr. Wheatley but I'm a bit confused about it.
A. There are various times we record for cardiac procedures such as this – Cross clamp time, bypass time, operative time. as with any “plumbing repair” (and valve surgery is essentially a plumbing job), the water (in this case blood) needs to be turned off. To “turn off the water” we clamp the aorta (ie cross clamp). We then need to stop the heart in an effort to fix it. Once your pump (your heart) stops, we need to substitute in our pump (the heart bypass machine – also known at the heart lung machine or simply “the pump”). The length of time you are on the pump is recorded. I suspect you’ll be on the pump 2-3 hours. I usually quote the total length of surgery as 4-5 hours and total time out of Dan’s sight about 6-8 hours. I always build into this estimate an hour at the beginning to set you up and an hour at the end to dismantle the equipment: (1 hour set up) + (4-5 hours surgery) + (1 hour dismantle) = 6-8 hours.
Friday, January 16, 2015
The good news is that unlike other aortic aneurysmal pathologies (Marfan Syndrome, Ehlers-Dahnlos Syndrome, etc), where aneurysm formation THROUGHOUT the aorta is a risk at all times… the bicuspid aortopathy is limited to the root and proximal 1/3rd of the ascending aorta only. The rest of your aorta is normal, and is not at any increased risk of aneurysm formation beyond that of the general population.
Thursday, January 15, 2015
You have a bicuspid aortic valve (“congenital anomaly” - most common one - present in about 2% of human population). It turns out that not only does having a bicuspid aortic valve result in early valve disease (stenosis, regurgitation or both), but it is also associated with an abnormal weakness of the most proximal portions of the aortic “root” and ascending aorta. It’s known as “bicuspid aortopathy”. It is a form of annuloaortic ectasia, and any dilatation of the proximal aorta is usually associated with sinotubular effacement (that’s just a descriptor, not a pathology). After much population-based research, it has been determined that an aortic root or proximal ascending aortic diameter of ≥4.5 cm portends elevated risk of further dilatation and aneurysm formation over the long term. Thus, it is recommended that in bicuspid aortic valve patients whose aortas are larger than that, the proximal aortic root be replaced as well. It’s more of a gray zone below 4.5, but I’ve cared for patients who’d had smaller aortas at the time of bicuspid aortic valve replacement, and then a few years later, needed to go BACK to the OR for replacement of an ascending aortic aneurysm. That is clearly a sub-optimal situation. With you proximal ascending aortic measurement of 4.6 on your recent CTA, it is most prudent to replace both the valve, root and proximal-most portion of the ascending aorta."
Tuesday, January 13, 2015
Dr. Grayson Wheatley
After I thought about the discussion I had last week with my surgeon, Dr. Wheatley, I had a few questions so I emailed Dr. Wheatley and my cardiologist, Dr. Keane. Dr. Keane responded immediately with answers to my questions, and Dr. Wheatley confirmed the information. Later in the day I posed a few more questions to Dr. Wheatley's assistant and once again I got an immediate comprehensive response. I am very with this team that I have selected for my cardiac procedure and care.
Monday, January 12, 2015
Bicuspid Aortic Valve and Aortopathy: See the First, Then Look at the Second
Rosario V. Freeman, MD, MS; Catherine M. Otto, MD
Bicuspid aortic valve (BAV) disease is the most common congenital cardiac anomaly, with a prevalence in the general population between 0.5% and 2% (1). There is significant cardiac morbidity associated with BAV disease, predominantly due to progressive valve dysfunction (stenosis or regurgitation) that requires surgical intervention for symptom relief or prevention of left ventricular dysfunction, or less commonly, for complications of endocarditis (2,3). We now understand that BAV disease is more than simply having 2, instead of 3, aortic valve leaflets. BAV disease encompasses a spectrum of phenotypic manifestations that not only includes valve dysfunction, but also abnormalities of the ascending aorta. Less common cardiovascular abnormalities may also occur, such as aortic coarctation, atrial septal defects, and ventricular septal defects.
. Long-term cardiovascular outcomes in adults with a BAV were defined in 2 recent clinical studies. In a series of 642 asymptomatic adults with a BAV, most (63%) had normal or mildly abnormal valve function at baseline. Over an average 9 years of follow-up, about 25% required surgery for symptomatic valve disease, left ventricular dysfunction, ascending aortic dilation, or endocarditis. Independent predictors of adverse cardiovascular events were age >30 years and at least moderate aortic valve dysfunction at baseline (3). Similarly, in another series of 212 asymptomatic adults with a BAV and at most mild valve dysfunction, primary cardiac outcomes were frequent over follow-up, occurring in 42% of participants. In this study, independent predictors for primary outcomes were older age (>50 years), presence of valve degeneration at baseline, and a baseline aortic dimension of >40 mm (2). Importantly, these studies demonstrated that although the cardiac morbidity associated with a BAV is significant, overall life expectancy is not shortened relative to general population estimates. In the Olmstead County study, survival was 97% and 90% at 10 and 20 years, respectively, from diagnosis (2). Similarly, in the Toronto cohort, 10-year survival was 97% (3).
. BAV disease is not confined to the valve leaflets; the aorta also is abnormal. Compared with normal adults with a trileaflet aortic valve, BAV patients have larger dimensions of the aortic sinuses and ascending aorta, abnormal aortic elasticity, and are at risk for progressive aortic dilation and dissection (4). In the past, aortic dilation was thought to be primarily a hemodynamic consequence of the eccentric ejection jet created by the bicuspid valve. However, histopathologic studies now support an underlying connective tissue disease process with elastin fragmentation, irregularities in smooth muscle integrity, and increased collagen deposition (5). Dilation is often progressive, with an average annual change in diameter ranging from 0.2 to 1.2 cm/year (6). Risk factors for more rapid progression of aortic dilation include hypertension, male sex, concurrent valve disease, and older age. In the study by Tzemos et al. (3), 280 patients (45%) developed dilation of the aortic sinus, ascending aorta, or both at follow-up. In a subsequent publication from the Olmstead County cohort, which included 416 patients, although 53% of patients eventually required aortic valve replacement, a significant portion of patients (25%) also ultimately required surgical intervention for aortopathy (6). Because not all patients are at risk for progressive aortic dilation, the clinical challenge is in identifying which patients are at highest risk for aortic complications and might therefore require more frequent imaging evaluation.
. In this issue of iJACC, a study by Kang et al. (7) focuses on the potential value of computed tomographic angiography (CTA) to more precisely define BAV phenotypes and to characterize the associated aortopathy. Typically, bicuspid valve cusps are asymmetric with fusion along a commissural line, which creates 2 cusps of unequal size. Similar to other series, this study found that fusion of the right and left coronary cusps (anterior–posterior [AP] leaflet type) was the most common pattern, occurring in 56% of patients, with fusion of the right and noncoronary cusps (right–left [RL] leaflet type) seen in the remaining 44% of patients. Although the study suggests that the RL phenotype is associated with valve stenosis and the AP phenotype with regurgitation, this should be considered a hypothesis, not a conclusion. All the subjects in this study were referred for preoperative CTA; thus, all had significant valve dysfunction and/or aortic dilation and should not be considered representative of an unselected group of BAV patients. Kang et al. (7) also found that leaflet phenotype was associated with different patterns of aortic dilation. Normal aortic shape and dimensions were seen more often in BAV patients with an AP leaflet phenotype, whereas those with a RL leaflet phenotype more often had aortic dilation extending to the arch. These findings parallel a study from our group that demonstrated larger and stiffer aortic sinuses with the AP phenotype and larger aortic arch dimensions with the RL leaflet phenotype (8,9). These differences in aortic anatomy and valve function associated with different valve phenotypes support the possibility that BAV disease is not a uniform disease process.
. Despite the insights into the disease process provided by this study, which was performed with computed tomography, from a practical point of view, echocardiography remains the key imaging approach in adults with BAV disease. CTA is only an adjunct in selected patients. BAV disease is usually asymptomatic, often incidentally diagnosed on echocardiography obtained for other indications or suspected on physical examination with auscultation of a murmur or a mid-systolic “click.” Transthoracic echocardiography has a high sensitivity and specificity for the diagnosis of a BAV. Characteristic findings include an eccentric diastolic leaflet closure plane and systolic doming of the leaflets in long-axis views. The number of valve leaflets, the type of leaflet fusion, and the presence or absence of a raphe can be reliably determined in short-axis views. Doppler echocardiography allows accurate measurement of the severity of valve stenosis and regurgitation. If transthoracic image quality is not adequate, transesophageal echocardiography often provides improved visualization of aortic leaflet morphology. Three-dimensional imaging of the aortic valve may further improve the accuracy of echocardiography for diagnosis of BAV disease.
. Echocardiography allows evaluation of the aortic sinuses and, by moving the transducer up 1 intercostal space, the proximal ascending aorta. Because of the low cost, lack of ionizing radiation, and wide availability, echocardiography is often used to evaluate and follow the aortopathy associated with BAV disease. However, for a more comprehensive evaluation of aortic anatomy, CTA or magnetic resonance angiography (MRA) both provide comprehensive tomographic evaluation of the entire aorta, and are particularly helpful when visualization of the ascending aorta by echocardiography is limited. Our approach in patients newly diagnosed with BAV is to obtain an index tomographic (CTA or MRA) imaging study of the aorta to determine the pattern and severity of aortic dilation. If there is no significant dilation or if echocardiography adequately visualizes the aorta, then serial routine CTA or MRA imaging is not indicated. In patients who have disease progression necessitating aortic valve replacement, aortic surgery, or both, pre-surgical CTA or MRA imaging provides a better understanding of the extent of aortic involvement to aid in surgical planning and graft choice.
. A majority of patients with BAV disease will have disease progression requiring surgery over the course of their lifetime, most often for valve stenosis or regurgitation, with established clinical guidelines providing recommendations on optimal timing of intervention (10). Clinical recommendations for surgical intervention for the aortopathy associated with BAV disease are less well defined, but most centers recommend intervention at an aortic diameter greater than ∼50 to 55 mm, independent of valve disease. Aortic graft replacement may also be considered at a smaller aortic diameter (45 to 50 mm) in patients who are otherwise undergoing aortic valve surgery or if there is evidence of rapid disease progression (interval increase in aortic diameter >5 mm over 6 months.)
. Although adults with BAV disease can have excellent clinical outcomes with appropriate disease monitoring and with correctly timed intervention to prevent adverse events, our current approach is largely pragmatic with little understanding of the underlying disease process. Several studies, such as the one by Kang et al. (7), suggest that there is more than 1 BAV phenotype with different clinical associations. Do these different phenotypes also have different genetics and different clinical outcomes? Until we can identify which patients with BAV disease are at risk for aortic dissection and would benefit from prophylactic aortic intervention, we will need to continue serial imaging of all BAV patients to detect the few who have progressed to surgical disease.
Saturday, January 10, 2015
Thursday, January 8, 2015
Wednesday, January 7, 2015
Tuesday, January 6, 2015
Sunday, January 4, 2015
Saturday, January 3, 2015
I'm meeting with two different surgeons next week. One is associated with the University of Pennsylvania hospital and the other with Temple University hospital, where my cardiologist works. I'm compiling a list of questions to ask. But first I will give each physician a chance to propose a course of treatment. I think I have to listen closely first before peppering them with a lot of questions. I've sent my records to both so they should have a pretty good idea of what they would do before I get there. I'm taking my husband Dan with me so we'll have four ears and two heads to process the information. The obvious questions are about AVR, (prosthesis type, etc.) and what to do about my aneurysm. Also, how quickly can surgery be scheduled? Other questions have to do with the surgery itself, but I don't want to get too far out ahead of things, like I was six years ago when I first met with a surgeon. It wasn't time then I was told, but I think it is time now. How many more heart attacks and strokes do I have to have?