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Juan Umana, MD, chair of Thoracic and Cardiovascular Surgery at Cleveland Clinic Florida, describes key considerations for when the aortic valve needs to be repaired or replaced.
Announcer: Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.
Juan Umana, MD: Hi, my name is Juan Umana. I’m the Chair of Thoracic and Cardiovascular Surgery at Cleveland Clinic Florida, and I’m here to talk to you about aortic valve regurgitation and timing of intervention for patients that might even be asymptomatic. Aortic regurgitation has become more prevalent as we identify patients, particularly patients with bicuspid aortic valve disease, which as we all know, is present in 1 to 2 percent of the U.S. population. What many people don’t know is that of those patients, a large percentage will present late with aortic stenosis, but approximately a third of them will present early in their 20s or 30s with severe aortic insufficiency. Those patients benefit from a repair of the aortic valve rather than replacement of the valve.
Our belief at Cleveland Clinic is that a multidisciplinary approach to the leaky aortic valve renders the best possible result for the patient, restoring their quality of life, but also their life expectancy, avoiding the need for a prosthetic valve, be it a mechanical or a tissue valve. So how do we approach the aortic valve with insufficiency? Our preferred initial test is an echocardiogram, which can be a transthoracic echocardiogram, followed by a transesophageal view of the heart and the aortic valve, allowing us to interpret exactly what we’re dealing with and what the morphology of the valve, and as a consequence, the insufficiency is.
With that information, we’ll proceed to get a CT angiogram, which will allow us to evaluate the morphology of the aortic roots, where there’s dilatation of the root, the sinotubular junction, the aorta-ventricular junction, or the ascending aorta. All of those components of the aortic root are critical in the evaluation and subsequent treatment of aortic insufficiency. When do we repair the aortic valve? We tend to approach these patients and get to them earlier than the posted guidelines, namely, operating on these patients when their ejection fraction drops below 60 percent is ideal as this will allow the ventricle to remodel in a reverse fashion completely. Whereas, if we wait for that ventricle to dilate to the usual 15- millimeter end systolic diameter or the ejection fraction of less than 50 percent.
If the patient has a dilated aortic root, our preferred approach is to replace the aortic root, re-implanting the aortic valve within the Dacron graft. That is called a Tirone David procedure or an aortic root replacement with vale re-implantation. If the aortic root is not dilated, our preferred approach is to do a repair of the aortic valve with or without an annuloplasty, which entails placing a support around the basal ring of the aortic valve. This will allow the aortic valve to function normally for at least another 10 to 20 years, avoiding the presence of a prosthesis in the aortic position, as a consequence, decreasing the risk of endocarditis or infection of the prosthetic valve and the need for anticoagulation or blood thinners long term.
A key element in the diagnosis and early intervention of aortic insufficiency is cardiac MRI. This test has emerged recently or is emerging as a mainstay in staging the degree of aortic insufficiency in a fashion that is more accurate than either transthoracic or transesophageal echocardiography. It is therefore imperative that we work in conjunction with imaging cardiologists, clinical cardiologists, as well as interventional cardiologists to diagnose this condition early and treat it as early as possible to guarantee the best possible result, as well as restoration of life expectancy and quality of life in these young patients with this condition. Please don’t hesitate to reach out to us with questions, even if the patient is not yet a candidate for surgery and close follow-up in conjunction with a surgeon will probably yield the best possible results for your patients as well as ours.
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