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A Focus on Valve-Sparing Ascending Aortic Aneurysm Repair Newyork

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A Focus on Valve-Sparing Ascending Aortic Aneurysm Repair Newyork ADVANCES IN CARDIOLOGY, INTERVENTIONAL CARDIOLOGY, AND CARDIOVASCULAR SURGERY Affiliated with Columbia University College of Physicians and Surgeons and Weill Cornell Medical College A Focus on Valve-Sparing NOVEMBER/DECEMBER 2014 Ascending Aortic Aneurysm Repair Emile A. Bacha, MD The most frequent location for aneurysms in the Chief, Division of Cardiac, chest occurs in the ascending aorta – and these Thoracic and Vascular Surgery aneurysms are often associated with either aortic NewYork-Presbyterian/Columbia stenosis or aortic insufficiency, especially when the University Medical Center aneurysm involves a bicuspid aortic valve. Director, Congenital and Pediatric Cardiac Surgery “We know that patients who have enlarged NewYork-Presbyterian Hospital aortas or aneurysms of the ascending aorta are at [email protected] great risk for one of two major life-threatening events: an aortic rupture or an aortic dissection,” Allan Schwartz, MD says Leonard N. Girardi, MD, Director of Chief, Division of Cardiology Thoracic Aortic Surgery in the Department of NewYork-Presbyterian/Columbia Cardiothoracic Surgery, NewYork-Presbyterian/ University Medical Center Weill Cornell Medical Center. “Dissection of the Valve-sparing ascending aortic aneurysm repair [email protected] inner lining of the wall of the blood vessel can also lead to rupture or other complications down last 15 years, the Aortic Surgery Program at Weill O. Wayne Isom, MD the line. For example, as the tear extends it may Cornell has been aggressively pursuing the devel- Cardiothoracic Surgeon-in-Chief NewYork-Presbyterian/ affect the vessels that supply the brain or the opment of a procedure that would enable surgeons Weill Cornell Medical Center coronary arteries or cause tremendous damage to to spare the patient’s native valve. Today, valve- [email protected] the aortic valve.” sparing ascending aortic aneurysm repair is a Traditionally, these patients would have their viable option for an increasing number of patients. Bruce B. Lerman, MD valve removed and replaced. “There wasn’t a “In the past, surgery for patients involved Chief, Maurice R. and Corinne P. great alternative to treat this condition from the either a biological valve replacement, which, Greenberg Division of Cardiology 1960s to early 2000,” says Dr. Girardi. Over the (continued on page 2) NewYork-Presbyterian/ Weill Cornell Medical Center [email protected] NewYork-Presbyterian/Columbia Welcomes Director of Aortic Surgery and Columbia Cardiovascular Institute CONTINUING In August 2014, internationally renowned heart In accepting his new appointments, Dr. Borger, MEDICAL EDUCATION surgeon Michael A. Borger, MD, PhD, joined who most recently served as Assistant Director of NewYork-Presbyterian/Columbia University the Department of Surgery at the Leipzig Heart For all upcoming Medical Center as Director of Aortic Surgery and Center and a Professor of Surgery at the University education events through NewYork-Presbyterian Hospital, Director of the Columbia Cardiovascular Institute. of Leipzig in Leipzig, Germany, notes, “Columbia visit www.nyp.org/pro. Dr. Borger’s experience and expertise in perform- obviously has an internationally recognized name ing complex aortic surgery, including root and in many different fields, including cardiovascular arch replacement and valve repair using both surgery. The main reason that I was interested traditional and minimally invasive procedures, in coming here was through personal connections. NewYork-Presbyterian will further enhance Columbia’s outstanding I had known Dr. Craig Smith, Surgeon-in-Chief, Cardiology and Heart Surgery ranks #3 in the nation. cardiovascular surgery program. In his leadership for quite a while and was always impressed by of the Cardiovascular Institute, Dr. Borger oversees his honesty and humbleness despite his world- a multidisciplinary approach to the diagnosis and renowned status. Through the recruiting process I management of cardiovascular disease. (continued on page 3) Advances in Cardiology, Interventional Cardiology, and Cardiovascular Surgery A Focus on Valve-Sparing Ascending Aortic Aneurysm Repair (continued from page 1) potentially, would fail in 10 to 15 years, or graft and removes the aneurysm while they would have to have a valve replaced retaining natural valve function in the with a metal valve that required them to be patient. “Dacron is a woven material that on anticoagulants for the rest of their lives,” has been used for aneurysm surgery since explains Dr. Girardi. “We can now repair the 1950s,” notes Dr. Girardi. “It’s really the aneurysm and save and reconstruct the the perfect blood vessel substitute. It lasts patient’s own native aortic valve in such a forever and it doesn’t require blood thin- way that it works fine, is quite durable, and ners. We then reattach the patient’s native the patient doesn’t need to be on blood thin- aortic valve inside the Dacron graft to ners. Also, the risk of needing to re-operate make it fit appropriately and make sure the on that valve is very, very low.” leaflets are working correctly. It’s a very According to Dr. Girardi, the ideal candi- complicated procedure, but one that we date for valve-sparing surgery is someone have particular expertise and experience in whose aorta is approximately 5 cm, even performing.” upwards of 5.5 cm, and whose aortic valve In the operating room, the cardiac anes- still functions fairly well. As a general rule, thesiology team utilizes 3D transesophageal he says, the procedure is particularly benefi- echocardiography (3D TEE) to visualize cial for younger patients. “We know that cardiac structure and function in real-time replacement with a biological valve, such as before surgery commences and during a cow or pig valve, definitely fails earlier in Dr. Leonard N. Girardi surgery. “3D TEE imaging can show us younger people,” says Dr. Girardi. “When we how far down the aneurysm goes and put a biological valve in older patients, the data is clear that it is which leaflets of the valve are not coming together well. Then likely going to last them the rest of their lives.” we’ll know the exact location of the leak and how severe it is,” Sparing the valve also obviates the need for patients to be says Dr. Girardi. “These images also serve as a road map for on anticoagulants for many years. “The risks associated with restoring the anatomy once we have completed the repair. blood thinners increase as you get older,” says Dr. Girardi. 3D TEE is not yet the standard of care everywhere, but I believe “It is certainly an advantage if you don’t have to take them.” it is headed in that direction.” Preoperative imaging studies include CT scan or MRA, as In approximately 70 percent of cases, the native valve will func- well as an echocardiogram. “All of our patients get an echo tion well for the remainder of the patient’s life, says Dr. Girardi. because we want to look at the valve and see how well the heart is squeezing,” says Dr. Girardi. For More Information In the valve-sparing ascending aortic aneurysm repair, the Dr. Leonard N. Girardi • [email protected] surgeon reimplants the native aortic valve inside a Dacron tube Marfan Syndrome and Ascending Aortic Aneurysms Patients with Marfan syndrome are at particular risk for aortic The valve-sparing procedure was not associated with greater aneurysms and aortic dissection. Defects in elastin-associated 30-day mortality or morbidity rates than valve replacement and, micrcrofibrils, predominately composed of fibrillin, leave the at one year, no differences were found in survival, valve-related aortic wall fragile and susceptible to dissection. A majority of morbidity, or major adverse valve-related events between the Marfan patients will develop some enlargement of the aorta; two groups. 85 to 90 percent will develop at least a minor aneurysm, and “There was concern that 7 percent of patients undergoing many will require aortic surgery at some time in their lives. valve sparing developed aortic regurgitation,” notes Dr. Girardi. With its large base of experience in aortic aneurysm proce- “This emphasizes the importance of the need for long-term dures, NewYork-Presbyterian/Weill Cornell was one of 19 inter- follow-up to determine durability of each procedure in this national surgery centers chosen to participate in the Aortic Valve particular population.” Operative Outcomes in Marfan Patients Study Group. “These patients often have a weakened or dilated aortic valve annulus,” Reference Article says Dr. Girardi. “The valve-sparing technique can help stabilize Coselli JS1, Volguina IV2, LeMaire SA1, Sundt TM3, Connolly HM4, the annulus, preventing further dilation after surgery.” Stephens EH5, Schaff HV6, Milewicz DM7, Vricella LA8, Dietz HC9, The Marfan Patients Study Group recently published results Minard CG10, Miller DC5; Aortic Valve Operative Outcomes in Marfan Patients Study Group. Early and 1-year outcomes of aortic root of a study in the Journal of Thoracic and Cardiovascular Surgery surgery in patients with Marfan syndrome: a prospective, multicenter, that compared outcomes at one year following aortic valve-sparing comparative study. Journal of Thoracic and Cardiovascular Surgery. 2014 or valve-replacing aortic root replacement in 316 patients with Jun;147(6):1758-66, 1767.e1-4. Marfan syndrome who had surgery between 2005 and 2010. 2 Advances in Adult and Pediatric Cardiology, Interventional Cardiology,Advances and Cardiovascular in Cardiology, Surgery Interventional Cardiology, and Cardiovascular Surgery NewYork-Presbyterian/Columbia Welcomes Director of Aortic Surgery (continued from page 1) On the Horizon for Mitral Valve Repair Coming from Europe where regulatory bodies are not quite as stringent as in the U.S., Dr. Borger points to his exposure to innovations in technology and techniques in mitral valve repair. “I am quite excited about adjustable mitral rings which a surgeon can modify under transesophageal echocardiographic guidance after taking the patient off cardiopulmonary bypass,” he says. “The mitral rings will be particularly helpful for functional mitral regurgitation, and especially for surgeons who do not do a lot of these operations.
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