Surgeon Q&A: Aortic Valve Repair & Valve Sparing Aortic Root Replacement with Dr. Ali Khoynezhad

Together, we have learned about many different types of surgical procedures used to treat heart valve disease and related cardiac disorders including coronary artery disease, atrial fibrillation and aortic aneurysms.

Two procedures that I’m continuing to hear about these days are aortic valve repair and valve-sparing aortic root replacement. To learn more about these unique approaches to aortic valve disease and aortic aneurysms, I recently connected with Dr. Ali Khoynezhad who is the Director of Aortic Surgery at Cedars-Sinai in Los Angeles, California. As you can see here, Dr. Khoynezhad has successfully treated 18 patients from this website.

Video Transcript of My Interview with Dr. Ali Khoynezhad

For the hearing impaired members of our community, you will find a written transcript of my interview with Dr. Khoynezhad below.

Dr. Khoynezhad: I am a Professor of Cardiovascular Surgery and Director of Aortic Surgery at Cedars-Sinai Medical Center. Over the last 13 years, I have performed 3,000 cardiovascular operations. Over 900 of them were heart valve operations. I was privileged to spend six months at Texas Medical Center — early in my career. I had a scholarship to work with Dr. Cooley and Dr. DeBakey. These are giants in the cardiovascular field and interacting with them was outstanding. I knew I was going to be a cardiac surgeon. I like cardiac surgery because I can impact the care and the health of a patient — dramatically and immediately. That’s a wonderful experience. I love it.

Dr. Ali Khoynezhad – Heart Surgeon

I do perform the entire spectrum of heart valve replacement and repair, but I specialize in aortic valve repair and valve sparing aortic root replacement.

In an aortic valve repair, you preserve the patient’s own valve and reconstitute the functional anatomy so the valve becomes competent again. It’s a very gratifying experience because a well-done valve repair is always superior than a valve replacement.

Valve repair has many distinct advantages compared to valve replacement. One of them is it has reduced thromboembolic events. These are events which can cause stroke in patients. The patient with valve repair that does not require anti-coagulation (e.g. blood thinners like Coumadin). They also have a lower infection rate, and the hemodynamic profile of valve repair is always superior than any valve replacement. In addition, there are some studies that suggest that patient who have valve repair may live longer than patient who have valve replacement.

David Procedure Valve Sparing DiagramDavid Procedure (Valve Sparing)

There are many techniques for repairing the aortic valve. We can categorize them in three different sections:

  • The first one has to do with reducing and fixation of aortic valve annulus or sinotubular junction.
  • The second category concentrates on repairing the cusp itself — such as cusp extension, adjusting the margin of aortic cusps, closure of little holes that happen naturally on the aortic valve.
  • Third, and last but not least, is the valve-preserving aortic root replacement. The David Procedure is the most commonly performed valve-preserving aortic root operation. We reduce the annulus of the aortic valve diameter. We also re-implant the valve within the Dacron graft and then hook up the coronary arteries back to the Dacron graft. This represents particularly a reconstructed aortic root.

My advice for patients is three-fold. First, they need to have a good, quality echocardiogram before the surgery. We need to understand what’s the functional anatomy of the valve, what’s the pathology, why is the valve leaking, and how we can approach the repair. Second, they need to choose a surgeon carefully. You need a high-volume surgeon with experience in aortic valve repair. Third, you need to choose an institution that has a good infrastructure and has great anesthesiologists as well as critical care doctor and nurses for good recovery.

Cedars-Sinai is the largest academic heart valve program in the West Coast. There are a few centers in the country or a handful of centers in the country that can compete with the volume as well as the spectrum offered at Cedars-Sinai. I think for patients who require heart valve surgery, Cedars Sinai has the entire breadth of operations.

I hope this helped you learn more about aortic valve repair and valve sparing aortic root reconstruction including the David Procedure. Many thanks to Dr. Ali Khoynezhad for sharing his clinic experiences and research with our patient and caregiver community.

Keep on tickin!

Adam Pick
Written by Adam Pick

Adam Pick is a patient, author of The Patient's Guide To Heart Valve Surgery and the founder of HeartValveSurgery.com.

To learn how Adam has helped millions of people with heart valve disease, watch Adam's video, subscribe to his free newsletter, or visit his Facebook, or Twitter pages.

  • Bill Gentile

    Adam, thank you for the interview. Great to see the passion and excitement of Dr. Khoynezhad and his work. Can I ask you to follow up on a future report for what types of patients would be candidates for valve repair? Is this reasonable for someone with BAV? If so, does it return the valve to its normal configuration? Thank you.

  • Eileen J. Hawkins

    Hi Adam,
    Just replied to your email about this aortic root restructuring. Although it is original valve sparing, I do not have my natural valve due to having it replaced three years ago in another heart surgery where my heart was so calcified they could not do anything but replace it with an undersized one which left me with SOB even after cardiac rehab.
    But as Dr. Roselli told us, they did what they could at the time. Good thing the research is moving ahead as quickly as it is. Thank you for your part in getting the word and videos. E. Hawkins

  • Zafar

    Dear Adam

    May we know that if a valve is already repaired, it can be repaired second time. This I am asking in relation to my son(age 15 years) who underwent subaortic membrane removal and aortic valve repair surgery due to AR II, in June 2009. After 4 years, Now the AR is again Moderate.

    I will appreciate Dr Ali response on re-repair of aortic valve.

    Thanks and regards

    Zafar Mahmood

  • Dr. Ali Khoynezhad

    Hi Bill,

    Most patients with leaking aortic valve are candidates for repair if they do not have significant calcification and plaque on the valve. This is especially true for patients with bicuspid aortic valve: most of these patients present much earlier with regurgitant (leaking) valve associated with aneurysm of the aortic root.

    In these cases, the aneurysm is removed and the valve diameter is reduced back to original configuration. On avocation, additional repair of the aortic valve leaflets is necessary to reduce the leakage of the leaflets.

    Thanks,
    Dr. Khoynezhad

  • Eileen J. Hawkins

    Hi Adam,
    I received this email again from you re: this drs. aortic valve sparing repair to the aortic root. As I stated on Mar. 27, previously, my aortic valve was replaced on Apr. 21, 2011 with an undersized bio-prosthetic valve because that was all the surgeon at that hospital could do. My heart was so calcified they could not do all that I need done now.
    I am scheduled with Dr. Eric Roseli at Cleveland on Wed. Apr. 9 for an aortic root rebuilding to receive a 25 mm new valve to replace the one from 2011a 21 mm which was all calcified for whatever reason they could not explain.
    Replacement of my mitral valve and repair of my tricuspid valve is planned as well as cleaning out some calcification of the ventricles, and replacing or opening of one of the three bypasses I had in 2011 that had blocked. They also need to check the pulmonary hypertension when this is all done to see if that will correct itself it with all the other things taken care of as I understand it.
    I will be admitted on Tues., Apr. 8 to be hydrated to protect my kidney function during the time on the hrt/lung machine with the possibility of my needing temporary dialysis until I stabilize.
    A lot of work plus my reaction to anesthetic present the surgeons with multiple problems calling for more aggressive surgery to accomplish this. Of course being a re-operation I am apprehensive of having all this to go through again and can only try to trust the drs.
    Dr. Roselli was honest with me saying this would be more invasive and complicated than last time, but assured me he would be watching out for my welfare.
    I have read this info which doesn’t really apply to me I guess. Thank you for sending it again. Hoping to continue ticking. E. Hawkins

  • DVB

    Am a big fan of repair over replacement when outcomes are improved. Many thanks to you Dr. Khoynezhad for advancing the state of the art to the benefit of many thousands of future patients.

  • Gangadharrao

    Sir, under went heart examination in our local area doctors. suggested me to go Aortic valve replacement calcified severely (AVR) . Suggest me that which type of operation and valve replaced ( Mechanical or Tissue) Which is the best for me. I am 63 years old. Guide me to take pre- surgery precautions until go for operation. If required my reports will be enclosed in the next mail.

  • JamesL

    Dr. Khoynezhad

    Very glad to hear that the aortic valve can be repaired!

    How do I find out the cause of my mild/moderate leaking aortic valve? And how would I know if there are significant calcification and plaque on my valve?

    Thank you!

  • Ali Khoynezhad, MD, PhD

    Hi James,
    An echocardiogram is the best initial modality to evaluate the reason for the leaking valve. A CT scan with or without contrast can show any significant calcification in the aorta including the aortic valve.
    I hope this answers your questions,

    A. Khoynezhad, MD

  • JamesL

    Yes, thank you very much for answering my questions Dr. Khoynezhad!

  • k Reddy, MD

    Hi Adam,

    glad that you have a website for valve surgeries. For better information, it is my opinion that the website consider to publish the health grade scores. Helps patients a lot.

    thanks

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