Heart & Vascular

Joseph Bavaria, MD, and International Thought Leaders Review Aortic Valve Repair

In September, the North American Aortic Valve Repair Symposium (AVRS) returned to Philadelphia. Directed by Penn Medicine's Joseph E. Bavaria, MD, Vice Chief of Cardiovascular Surgery and Director of Thoracic Aortic Surgery, and co-sponsored by the University of Ottawa Heart Institute, this year's symposium was notable for both breadth of content and an intercontinental perspective on aortic repair surgery. 

 

Aortic Valve Disease

Aortic valve disease occurs in two forms, aortic stenosis and aortic insufficiency (AI), both of which conclude in end-stage heart failure. Stenosis, or narrowing, of the aortic valve can have a congenital etiology (bicuspid valve), but is more often caused by calcification or scarring at the valve. Aortic insufficiency is a consequence of valve leaflet failure allowing blood to leak back into the left ventricle (regurgitation). Over time, the left ventricle becomes larger and weaker as a result.

 

AVRS: An International Gathering of the Minds

Since its inception, the AVRS has invited an international panel of thought leaders, and the 4th Symposium was no exception. Keynote Speaker Hans-Joachim Schäfers, MD, of Germany, and Honorary Speaker Gebrine El Khoury, MD, of Belgium, shared their experiences on aortic valve repair and bicuspid aortic valve repair, respectively. 

A partner since the first AVRS in 2015, Co-Director Munir Boodhwani, MD, is a cardiac surgeon in Ottawa, Ontario, Canada, and a co-author of two recent Canadian Guidelines statements on medical and surgical management of thoracic aortic disease. Dr. Boodhwani was one of six Canadian presenters at this year’s symposium. 

Drs. Boodhwani, Schäfers, El Khoury and Bavaria also collaborated in June 2019 at the Aortic Valve Repair Summit, the world’s largest international gathering of aortic valve repair specialists.

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Physiologic Principles, Case Presentations and Debates

A key portion of the opening day’s morning agenda at the AVRS was devoted to finding consensus among advocates of the American, Canadian and European guidelines for the timing of surgical intervention in ascending aortic aneurysms. Treatment guidelines rarely coincide, whether they originate within organizations or across national boundaries, and those for aortic disease are particularly divergent.

 

 

National and International Treatment Guidelines

In an interview, Dr. Bavaria cited practical conflicts with current U.S. guidelines and differing interpretations between the international guidelines, as concerns, and offered as an example a case presented for debate at the Symposium. An active 45-year-old man with severe asymptomatic aortic insufficiency (AI), the patient’s case was complicated by a bicuspid valve and left ventricular dysfunction.

“As it is now, the current guidelines, offer little clear direction for treatment,” Dr. Bavaria said. “If you adhere strictly to the guidelines, you’d opt for watchful waiting.” However, citing factors defined as contributors to AI within the same guidelines, he continued, one could also find sufficient cause for surgical intervention.

 

 

A bright light of consensus is evolving, however, with the development of a new repair-oriented classification system for aortic insufficiency (AI), according to Dr. Boodhwani. The system provides a common language for  surgeons as they observe a valve prior to and during surgical repair.

“Heretofore, surgeons have been hampered by the absence of a common framework for valve assessment to guide the approach to valve repair in aortic insufficiency,” Dr. Boodhwani explained. “The new classification system allows us to systematically address AI according to the mechanisms of disease and the repair techniques used.” 

He concluded that the language of the new System is beginning to influence surgical discussion of aortic repair across national and international borders.

 

Complex and Engaging: AVRS Curriculum

The complexity suggested in the patient case study above was evident in the presentations that followed throughout the symposium, which involved valvular and aortic root pathology in the context of aortic valve preservation, discussion panels focusing on the technical nuances and detailed differences in aortic valve repair, valve-sparing aortic root techniques, and live-box offerings, among much else:

  • Natural History of Aortic Insufficiency (AI), MRI vs Echo, and Guidelines for Medical and Surgical Management
  • Annuloplasty Techniques for Isolated Aortic Valve Repair
  • Complex Trileaflet Aortic Valve Repair
  • Valve Sparing Surgery in Aortic Dissection
  • How to Manage Cusp Calcification and Restriction
  • When Repair is Not Possible: Outcomes of Biologic vs Mechanical Prostheses in Young Adults and Outcomes of Preserving Sinus Segment with Ascending/Arch Resection
  • Ross Procedure in Aortic Insufficiency
  • Bentall Aortic Root Procedure – Review of the Mayo Clinic Experience
  • Conduit Choice in BAV Root Reimplantation/Remodeling – 2 Schools of Thought: Straight vs Valsalva Grafts
  • Emerging Role of TAVR in Treating Aortic Insufficiency

When interviewed at the symposium, Dr. Bavaria reflected on recent advances in bicuspid aortic repair.

“I think the greatest stride we’ve made is in understanding bicuspid aortic valve insufficiency from an anatomical standpoint,” he said. “It’s really a very exciting time to be in the thick of it for bicuspid aortic valve repair.”