Surgical Repair of the Bicuspid Aortic Valve: Predictors of Failure
Surgical strategies in patients with bicuspid aortic valve (BAV), aimed at either correcting valve dysfunction, managing the BAV-associated aortic dilatation, or both, are diverse. Aortic valve replacement (AVR), with or without replacement of the proxima
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Maude Pagé and Jean-Louis Vanoverschelde
43.1 Introduction Mechanical valves are associated with the risks of thromboembolism, valve thrombosis, and anticoagulation-related bleeding, whereas biological valve substitutes undergo structural degeneration and expose the patients to the risk of reoperation. The risk of prosthetic valve endocarditis also remains high for both biological and mechanical substitutes. Taken together, the cumulative risk of valve-related complications has been estimated to be around 50% at 10 years in patients undergoing AVR for the treatment of AR [1–3]. In young patients with a stenotic aortic valve, the Ross procedure represents an interesting alternative to conventional AVR. When performed by experienced surgeons, the Ross procedure has indeed been shown to be durable, to avoid the hazards of anticoagulation and to improve survival when compared to AVR [4]. Yet, in patients with BAV, it was shown to be associated with an increased risk of pulmonary autograft failure, resulting in recurrent aortic
regurgitation (AR), dilatation of the neo-aortic root, and eventually reoperation [5, 6]. To minimize the complications related to AVR and the Ross procedure, valve repair and valve- sparing techniques have been developed and evolved over the past two decades from an anecdotal approach to a plausible alternative to AVR. Although these valve-sparing techniques have been proven to be safe and effective in selected patients with BAV, with survival rates of 97% and 94% at 8 and 10 years, respectively, and low rates of thromboembolism and bleeding events, their durability in this very setting has been questioned [7, 8], as patients with BAV are frequently operated on at a much younger age than patients with tricuspid AV disease [9–13]. In this chapter, we will review and discuss the currently available data regarding BAV repair failure, with a focus on the identification of preoperative, intraoperative, and postoperative echocardiographic and anatomical features associated with repair failure.
43.2 Repair Failure: Epidemiology M. Pagé Division of Cardiology, Hôpital du Sacré-Coeur de Montréal, Montreal, QC, Canada J.-L. Vanoverschelde (*) Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium e-mail: [email protected]
With rates of AR recurrence and need for reoperation reaching 30% in initial series, concerns about the durability of AV repair have clearly limited the diffusion and widespread use of valve-sparing interventions [14, 15]. Thanks to an improved understanding of the functional
© Springer-Verlag GmbH Austria, part of Springer Nature 2019 O. H. Stanger et al. (eds.), Surgical Management of Aortic Pathology, https://doi.org/10.1007/978-3-7091-4874-7_43
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anatomy of the AV and root, the development of tailored cusp repair techniques, and the acknowledgment of the role of the functional aortic annulus (FAA) stabilization, results of contemporary single-center series have become more satisfying, w
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