Chapters Transcript Video Bicuspid Aortic Stenosis with Aortopathy I wanted to take an opportunity to have a little bit of debate here, but it was very nicely introduced by steve at the outset, I think that for those of you who know me know, I've been a strong advocate for trans catheter valve therapies for a long time. Clearly commercially in this country over the last decade, it's absolutely exploded and the prior decade it exploded in europe. And even then and before in the research labs and it's it's truly fascinating technology. I mean, in short, it's just cool stuff. But I think that as the other speakers have alluded to our job is more than just that. Our job is to absolutely evaluate every patient, every circumstance, every nuance and to come up with the right the right treatment and the others have have definitely mentioned that. So uh there are times when it's our obligation to let people know, well you've heard about to have our you think that's what you want, but that might not be what is best for you. And it takes some time sometimes to backtrack those folks a little bit. Um so this is not meant to be a comprehensive list. I will note that by custom it is down there just to be compliant with my my topic. But these things are as you'll see a lot of them are incompetent things which Deepak mentioned. Uh so they have aortic stenosis and they have another problem um in a few of these circumstances, only surgery can solve the other problem and some of the circumstances their options there as well, which is the last case that matt talked about was an example. Um so just to run through that really quickly, um, here's a patient within a standing aortic aneurysm. This is a picture from the head of the table. Uh patient had aortic stenosis uh in general. Um 45 millimeters. Just what we use if it's a standalone aortic stenosis. That, I mean uh aortic aneurysm, it's a different number but with concomitant disease, 45 millimeters is generally what's used. Um and you know, here's a shot a picture into that patient's route that's a, the aortic valve is still in and that's the non coronary sinus, which is dilated and sometimes you see them dilated even more than this. Um This is a valve conduit going in uh and then the completed operation that took care of two of the patient's problems. Um So, uh and and I'll also say that as um surgery just because it existed. And then Tavern came along. And so steve as you alluded to, especially early on, some of the goals of Tavern were to, can we be as good as the Savar. Um The fact that that's increasingly occurring is also pushing on the surgery side now. Right. You know, so you talked about the root enlargement. Uh there's new um uh tissue valves with new types of treatment. One of the companies that come out with. Uh and of course even expandable surgical frames. So I think this point counterpoint in this, pushing back and forth is advancing both sides of the field. And 20 years ago, surgeons maybe there wasn't another option. So surgeons did the best they could put a valve in. And they didn't think as much, they did a little, but they didn't think as much about that 19 millimeter valve as they do now. We almost never ever put 19 valve in now, like 25 years ago. Yeah, once in a while. So that's sort of the push and pull Uh concomitant coronary disease is very common. And of course, uh you can do to var and PCI there's some trials even open related to this, but especially again on the surgery side with more and more arterial grafting. And a younger patient, that patient may be best served with the surgical a VR and multiple arterial grafting. Um and if the structural deterioration of the surgical valve occurs 10 years later, then, um that patient would certainly get a tavern probably at that point. Um and then of course, the younger patient, the debate about where that line is uh is out there 65 is the guidelines. But um certainly a lot of patients in their earlier 60s may just choose to go with a tissue valve or a tavern valve multi valve disease has been noted. I think all these patients should should have a surgical opinion unless they're just in extremists, there again are multiple structural heart options for this patient. But I think the surgical options should be clearly presented to the patient as often, that will be the better choice. Um So, um I'll just say that um some of the other indications, of course endocarditis is that's probably gonna go surgery uh whether it's native or prosthetic. Um And then the bicuspid valve in the misshapen root, I think we've actually pushed the envelope there a little bit uh and shown that in a lot of bicuspid valves, you can do a tavern valve successfully. But occasionally that route is to oval or to miss formed to to take a tavern valve. And you may consider surgery or or an analyst that's really large. Uh And also aortic insufficiency has been touched on. And uh you know, are we gonna have a structural heart valve that can solve that problem? We don't quite yet. But as you alluded to, there's one in trials, um the other thing I just wanted to touch on real quick uh is, well, a lot of what we've talked about so far is patient selection and which is the right valve and which is the right approach. And what's lifetime management and all these things are critical, but there are some surgical implications for when the Tavern procedure goes bad. Um And it's just again, the importance of the heart team is the importance of the surgeons being there were present for every tavern valve that's put in and these things are rare, but they happen uh and with a good surgical team you can save some of these patients. Um aortic root rupture after a tavern implant uh is rare, but we have had uh one I think she was 89 or 90 year old lady who was felt to be too high risk for an elective surgical a VR. But when her route ruptured and she had an emergent aortic root repair at 90 and then walked back in the clinic a year later. We were pretty proud of that and that that was again a tribute to having an excellent surgical team and an aesthetic team as well. That was right. They're able to jump in and save that patient coronary obstruction can certainly usually be fixed with trans catheter modalities but could could be an emergent surgical indication. A loss valve can also be fixed. Trans catheter sometimes by pinning it and putting a new valve in, but also sometimes occur surgery. Um early val favor. We talked a lot about valve failure. And then earlier, I had also mentioned the problems with patient prosthetic mismatch. Not so much at the first operation or the first tab bar, but as you go through those failures that lifetime management and you're talking about a second or third procedure. You do reach certain limitations. Um So thanks for your time and I'll be happy to answer any questions Published Created by Related Presenters Joseph Newton, Jr, M.D. Sentara Mid-Atlantic Cardiothoracic Surgeons View full profile
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