Recent Advances in Aortic Valve Disease: Highlights From a Bicuspid Aortic Valve to Transcatheter Aortic Valve Replacement

• Published in: Journal of cardiothoracic and vascular anesthesia 2009-08, Vol.23 (4), p.569-576
• Main Authors: Augoustides, John G.T., MD, FASE, FAHA, Wolfe, Yanika, BA, Walsh, Elizabeth K., RN, Szeto, Wilson Y., MD
• Format: Article
• Language: English
• Subjects: Anesthesia & Perioperative Care; aneurysm; aortic regurgitation; aortic stenosis; Aortic Valve - abnormalities; Aortic Valve - physiopathology; Aortic Valve - surgery; Aortic Valve Insufficiency - physiopathology; Aortic Valve Insufficiency - surgery; aortic valve reimplantation; aortic valve remodeling; aortic valve repair; Aortic Valve Stenosis - physiopathology; Aortic Valve Stenosis - surgery; bicuspid aortic valve; Critical Care; dissection; echocardiography; functional mitral regurgitation; Heart Valve Diseases - physiopathology; Heart Valve Diseases - surgery; Heart Valve Prosthesis Implantation - trends; Humans; low gradient aortic stenosis; partial sternotomy; prosthesis-patient mismatch; transcatheter aortic valve replacement
• ISSN: 1053-0770; 1532-8422
• DOI: 10.1053/j.jvca.2009.03.020

There have been major advances in the management of aortic valve disease. Because bicuspid aortic valve is common and predicts an increased risk of adverse aortic events, these patients merit aortic surveillance and consideration for ascending aortic replacement when its diameter exceeds 4.0 cm. Serial quantitative echocardiographic analysis, as compared with traditional clinical markers, can result in better timing of surgical intervention for aortic regurgitation. Furthermore, echocardiographic analysis of aortic regurgitation can classify the mechanism based on cusp mobility to guide aortic valve repair. In aortic root replacement, aortic valve preservation with reimplantation is a mainstream surgical option in Marfan syndrome to offer freedom from valve-related anticoagulation. Prosthetic aortic root replacement has further alternatives with the introduction of the aortic neosinus design and acceptable clinical outcomes with the porcine xenograft. Because aortic valve prosthesis-patient mismatch (PPM) may adversely affect patient outcome, its perioperative prevention is important. Furthermore, significant functional mitral regurgitation in association with aortic stenosis often resolves after aortic valve replacement. Echocardiographic assessment of the aortic valve must include valve area because the transaortic pressure gradient may be low in severe stenosis. Aortic valve replacement with partial sternotomy is safe and offers a reasonable less invasive alternative. Transcatheter aortic valve replacement, whether transfemoral or transapical, has revolutionized aortic valve replacement; it remains a major theme in the specialty for 2009 and beyond.