Surgeon Roundtable: Aortic Valve and Aortic Aneurysm Interaction and Treatment
Written By: Allison DeMajistre, BSN, RN, CCRN
Medical Experts: Eric Roselli, MD, Chief of Adult Cardiac Surgery and Director of the Aortic Center, and Xiaoying Lou, MD, Cardiac Surgeon, Cleveland Clinic
Reviewed By: Adam Pick, Patient Advocate, Author & Website Founder
Published: September 23, 2024
The aortic valve is the gateway for oxygenated blood to leave the heart and circulate throughout the body. That said, the aortic valve is a complex and vital component of human life.
Unfortunately, several problems are related aortic valve function, including aortic stenosis and regurgitation. Additionally, since the aortic valve structure is part of the aorta, when the valve doesn’t work correctly, it can create complications including an aortic aneurysm, which can be life-threatening.
At HeartValveSurgery.com, we receive several questions about aortic valve disease from our community considering (i) aortic valve defects are the most common type of heart valve disease and (ii) there are many different treatment options available to patients from standard aortic valve replacement and aneurysm repair to complex valve-sparing aortic root replacement.
To learn more these two associated aortic diseases, we sat down with two highly skilled heart surgeons from the Cleveland Clinic. Dr. Eric Roselli is the Chief of Adult Cardiac Surgery and Director of the Aortic Center. Dr. Xiaoying Lou is an expert cardiac surgeon with extensive experience managing and treating aortic valve disease and aneurysms.
Key Patient Insights About Aortic Valves and Aortic Aneurysms
Here are key insights shared by Dr. Roselli and Dr. Lou during the surgeon roundtable:
The structure, the complexity and the embryology of the aortic valve
Dr. Roselli stated, “The aortic valve is a really complex structure, and embryologically, it develops in unison with the aorta. And the aortic structure is critical to the way the aortic valve works. As I’ve been staring at so many thousands of aortic valves over the years, I think I’ve gained a better appreciation of how that works and the embryologic development and the subtleties of how the valve forms probably have a bigger impact than we ever realized on the later dysfunction of that valve. It has to open and close a hundred thousand times a day. Over a lifetime, it could be like three billion cycles of wear and tear.”
Dr. Eric Roselli (Cleveland Clinic)
How to think about the aorta when a patient is told they have a bicuspid aortic valve that needs to be addressed
Dr. Roselli said that since more and more treatment options are available, they can appreciate the interaction between the aorta and the aortic valve. “I think one of the most common things we see is a bicuspid aortic valve, or what gets lumped into a bicuspid aortic valve, which is really a malformed valve,” he said.
Dr. Lou said that although statistics show that about two to three percent of the population have a bicuspid valve, that number is only based on people who come in for treatment and have a confirmed diagnosis. “So, I bet the prevalence of the bicuspid valve is a little higher than that,” she said. “Patients who have a bicuspid valve are born with it.”
She explained that a normal aortic valve has three leaflets, but there can be different forms of bicuspid valves which have just two leaflets. “There can be these raphe that form and are either completely bicuspid, or they can have different leaflets that are fused. Based on different fusion patterns of those bicuspid valves, there are different associations with aortas that can develop abnormally.”
Dr. Lou continued, “I think the debate is still out whether it’s because of the bicuspid valve and these associated aortopathies, these aneurysms that grow in association with the bicuspid valves, or whether it’s because of the valve getting stenosed that causes some of these hemodynamic pressure issues in the aorta that’s also causing those aortas to get bigger.”
Dr. Xiaoying Lou (Cleveland Clinic)
Dr. Lou explained that when a patient is diagnosed with a bicuspid valve, medical teams should also check their aortas because a bicuspid valve is often associated with aneurysms at the aortic root level, ascending aorta, or aortic arch. She also said, “They also have things inside the heart that may be malformed as well. There are a lot of other things we need to look at to diagnose that patient.”
Dr. Roselli explained that a bicuspid valve presents a constellation of problems in many different patterns. “The estimate is that at least a third and probably half of people with a bicuspid valve diagnosis are prone to develop an aneurysm. We did a study where we looked at unicuspid valves, another kind of malformed valve, which should be lumped into the same space, and they also had about the same incidence of aortic aneurysms. Sometimes, we see it involves the root and sometimes the ascending aorta. So, there is a lot of complex decision making, not just about what we do with the valve, but what we do with the aorta, including whether we deal with the root or we extend into the arch.”
Aortic valve repair versus replacement when addressing an aneurysm
Dr. Lou said that she’s seen a lot of bicuspid valve repairs since coming to the Cleveland Clinic under her fellowship with Dr. Roselli. She recognized that while not everyone is repairing bicuspid aortic valves, Dr. Roselli has built a huge practice of doing them.
“There are different repair techniques, but we do a lot of valve-sparing root replacements here where, if that valve does not have a lot of calcium with it or fenestrations or isn’t otherwise damaged and has pretty pliable leaflets, they can be reconstructed in a way where we can save that valve. It offers really good durability for that patient long-term without the need to replace the valve and no need for anticoagulation if they’re a young patient not getting a mechanical valve. And that has been a really good adjunct procedure to a valve-sparing root replacement, for instance, if the aneurysm has been the main issue for that patient.”
Dr. Roselli said, “The idea of keeping a living valve is going to be better than replacing one. I think it’s important for people to know that if you go down that pathway, you still have a bicuspid valve. We want to have a lifelong view of things, so it’s important to continue to follow that.”
He went on to say that the hope is that some of the patients in their 20s or 30s who need a valve-sparing procedure may reduce the number of lifetime operations.
“We also have other choices for dealing with it as well,” he said. “Certainly, the Ross operation is something we’ve been doing more of, and we’re going to see better artificial and prosthetic valves, both biologic and mechanical. And I think one of the things that’s important to remind the patients is that although we don’t have the perfect options, we have a lot of really good options and can tailor them to the patients. And I think it’s important to be at a center that offers all those different options.”
What about transcatheter aortic valve replacements explants, pacemaker rates and calcium removal?
Dr. Roselli said, “I think it’s reasonable in older patients where the risk of that transcatheter valve matches the risk of a surgical valve or maybe reduces the risk compared to a surgical valve. But of course, there’s a lot of excitement when people think, ‘Oh, I can have this taken care of without opening my chest.’ But there are definitely some downsides to that.”
Dr. Lou said, “It’s a great option for patients who are in the higher risk category and there are many studies out there also suggesting this is non-inferior to a surgical valve replacement in lower risk patients.” Dr. Lou points out, however, that while they always have a heart team approach at the Cleveland Clinic when evaluating patients for a transcatheter versus a surgical valve option, they favor doing open surgery on a patient who is young and otherwise healthy. “We still don’t have great durability data, and certainly the number of TAVR explants and the people who need TAVR explants has increased over the years, and we’re seeing more of those getting infected, and we have to explant those. The paravalvular leak rate for TAVR valves is getting a lot better, and the pacemaker rates are way better, but they’re still there. The difference is we can’t remove all of the calcium in a transcatheter valve, but we can do that in an open valve. I do think, especially for patients with bicuspid valves, you get in there and see how calcified it is, and I think if it were my valve, I would want it out, and I’d want it debrided and have a new valve put in place of it.”
“It’s nice to put a valve in a clean space,” said Dr. Roselli. “But also, if you have some potential risks for aneurysm, a TAVR will not address that. We’ve seen some pretty bad problems where people have pushed that technology into that abnormal space.
What about safety and overall outcomes?
Dr. Roselli said, “I think it’s also essential for people to understand how safely we can do these operations. Everybody is afraid of having an incision in their chest, and I get that; why wouldn’t you be? But our outcomes are outstanding, and we just presented all of our annual outcomes recently. They’re pretty great.”
“Yes,” said Dr. Lou. “I don’t have the valve data, but I have the root replacement data in elective cases.” She explained that the mortality rate for the root replacement data is only 0.5%.
“Pretty awesome,” said Dr. Roselli. “Also, these patients can get back to normal life afterward. I have patients who are competitive athletes after they go through all of this, and I think that’s something that people need to appreciate.”
Patients can make decisions for themselves with good support and education
Dr. Roselli said, “That’s one of the beauties of the HeartValveSurgery.com website: patients talking to patients, and they share their stories, and they reassure each other that, even though this is a scary ordeal, there’s a really good chance you’ll get through it safely and get back to a high quality of life.”
He explained that the new technology they’ve been working on at the Cleveland Clinic has made operations for aortic valve and aortic disease safer and easier. “More importantly, we are providing people good, high quality, lifelong care. We are here to help educate people about that so patients can make the best decisions for themselves in a precise way with all the options at hand.”
Thanks Dr. Roselli, Dr. Lou and the Cleveland Clinic!
On behalf of the HeartValveSurgery.com patient community, thank you, Dr. Roselli and Dr. Lou, for helping us understand more about the aorta and aortic valve and the treatments that are now available. We would also like to thank the Cleveland Clinic for continuing to care for heart valve patients and keep them informed!
Related Links:
- Surgeon Q&A: Advanced Aortic Valve Techniques with Dr. Roselli
- Patient Success Story: Ari & Dr. Roselli Aortic Valve Reoperation
- Bicuspid Aortic Valve & Valve-Sparing Root Replacement: Top 8 Facts
Keep on tickin,
Adam
Written by Adam Pick
- Patient & Website Founder
Video Transcript:
Dr. Eric Roselli: Hi, I’m Eric Roselli, the Chief of Adult Cardiac Surgery and the Director of Our Aortic Center. And I’m here with one of our greatest staff surgeons.
Dr. Xiaoying Lou: Appreciate the introduction. I’m Xiaoxiao Lou, I go by Xiaoxiao.
Dr. Eric Roselli: It’s been so great to have you as part of the team. You’ve fit in seamlessly with us and it’s been so fun working together.
And, it’s fun for us to have an opportunity to. To chat to, to an audience about what we do every day. You know, we do this in the hallways with the team all the time and sharing it with the HeartValveSurgery.com audience is a really nice opportunity. So thanks to everybody who’s listening.
We thought that we would talk a bit about, the interaction between aortic valve and aortic disease. I think it’s important to understand, um, that when we talk about the aortic valve. It’s not just some, you know, flaps in the middle of a pipe somewhere, like we think about sort of man made valves.
The aortic valve is a really complex structure, and embryologically, it develops in unison with the aorta. And the aortic structure is really critical to the way the aortic valve works. And, you know, as I’ve been staring at so many thousands of aortic valves over the last years, I think I’ve gained a better appreciation of how that works – the embryologic development and the subtleties of the way the valve forms probably has a bigger impact that I think than we ever realized on the later dysfunction of that valve. It has to open and close a hundred thousand times a day. Over a lifetime, it could be 3 billion cycles of wear and tear.
It’s been really kind of cool as we have more and more treatment options available that we can kind of appreciate that interaction between the aorta and the aortic valve=. I think one of the probably most common things we see is bicuspid aortic valve or what gets lumped is bicuspid aortic valve, which is really kind of a malformed valve.
I know that in this place you’ve gotten a large experience with that in a short period of time. Can you share with the audience some of your thoughts about how we need to think about the aorta when a patient is told they have a bicuspid valve that needs to be addressed.
Dr. Xiaoying Lou: The bicuspid valves, I think we hear in incidence about two to three percent in the population, but that’s really, I think, based on people who come here and we actually study their aortic valves and know that they have a diagnosis.
I bet the prevalence of the bicuspid valve is a lot higher than that. But, patients who have a bicuspid valve, obviously they’re born with it. A normal aortic valve has three leaflets and the bicuspid valves can be various forms of the bicuspid valves.
They can be these raphes that form and either completely bicuspid or they can have different leaflets that are fused. Based on different forms, fusion patterns of those bicuspid valves. There’s different associations with aortas that can also be developed abnormally. So, I think the debate is still out whether it’s, um, just because of the bicuspid valve and these associated aortopathies that we see, these aneurysms that grow in association with the bicuspid valves, or whether it’s because of the valve getting stenosed, causing some of these abnormalities, hemodynamic pressure issues in the aorta that’s also causing those aortas to get bigger.
Anyone who has a diagnosis of a bicuspid valve, we need to check their aortas as well, because they are often associated with aneurysms, either at the aortic root level or ascending aneurysms or arch aneurysms that are associated with them.
And they also have things that can happen inside the heart that may be malformed as well. There’s a lot of other things that we need to be looking at to diagnose that patient and work them up.
Dr. Eric Roselli: It’s kind of a constellation of problems and we see it in so many different patterns.
It’s interesting. The estimate is that at least a third and probably half of people with a bicuspid valve diagnosis are prone to develop an aneurysm. We did a study where we looked at unicuspid valves, another kind of malformed valve, which all really should be lumped into the same space.
They also had about the same incidence of aortic aneurysms. Sometimes, we see it involves the root and sometimes it’s the ascending aorta. So, there’s a lot of complex decision making, not just about what we do with the valve, but what we do with the aorta including whether we deal with the root or we extend into the arch and, and so you want to really be facile with your, with your aortic operations when you’re doing that.
Increasingly, we’re repairing a lot of these valves now instead of replacing them when we when we’re there to address maybe the aneurysm or something. Can you tell us about that?
Dr. Xiaoying Lou: I’ve seen a lot of this in training in my fellowship here with Dr. Roselli and was able to see that. see a lot of that because you, you know, not everyone is repairing bicuspid aortic valves, but you, you know, obviously built up a huge practice of this.
There are different repair techniques but we do a lot of valve sparing root replacements here where if that valve does not have a lot of calcium with it or fenestrations or is otherwise damaged and has pretty pliable leaflets, they can be reconstructed in a way where we can save that valve and that offers really good durability for that patient long term without the need to replace the valve and no need for anticoagulation if they’re a young patient so that they’re not getting a mechanical valve in that position.
And that’s been a really good adjunct procedure to a valve sparing root replacement, for instance, if the aneurysm has been the main issue for that patient.
Dr. Eric Roselli: Our hope is that the idea of keeping a living valve is going to be better than replacing one. I think it’s important for people to know, though, that if you go down that pathway, you still have a bicuspid valve and we want to have sort of a lifelong view of things. So, it’s important to kind of continue to follow that. Hopefully, some of our patients who are in their 20s or even 30s that need this done we’ve maybe reduced the number of operations they’ll need in a lifetime. We have other choices for dealing with it as well.
Certainly the Ross operation is something we’ve been doing more of. We’re going to see better artificial valves, prosthetic valves, both biologic and mechanical. And I think one of the things that’s important to remind the patients is that although we don’t have the perfect options, we have a lot of really good options and we can kind of tailor it to the patients. And I think it’s important to be at a center that offers all those, all those different options. We’re also seeing a lot of people though, asking us now about transcatheter valves.
Dr. Xioaying Lou: Right.
Dr. Eric Roselli: I think that’s totally reasonable in older patients where the risk of that transcatheter valve totally matches the risk of a surgical valve or maybe reduces the risk as compared to a surgical valve.
But, of course, there’s a lot of excitement when people think, Oh, I can have this taken care of without opening my chest at all. But there’s definitely some downsides to that.
Dr. Xioaying Lou: It’s a great option. I think for patients who are, you know, in the higher risk category and obviously there are many, many studies out there that are.
You also suggesting that this is, you know, non-inferior to surgical valve in, in lower risk patients. But really when we come in and, and it’s always a heart team approach to evaluate a patient for a transcatheter option versus a surgical aortic valve option. But, here at the Cleveland Clinic, I think we really favor doing open surgery on someone who’s young and otherwise healthy because, um, the durability of the TAVR valve, we still don’t have great durability data and certainly the number of TAVR explants and the people who need.
TAVR explants have, I think, increased over the years and we’re seeing more of those and sometimes they get infected and then we have to explant those and I think we’re seeing a higher threshold of those patients and, you know, the paravalvular or leak rate for the TAVR valves is getting a lot better and the pacemaker rates are way better, but they’re still there and the difference is that we can’t remove all of the calcium. In a transcatheter valve, and you do that in an open valve. So, um, I do think, you know, especially for patients with bicuspid valves, you get in there and see how calcified that is. Um, you know, I think if it were my valve i’d, I’d want it out and I’d want it derided and have a, you know, a new valve put in, um, in, in place of it.
Dr. Eric Roselli: So it’s nice to put a valve in a clean space. But also if you have some potential risks for aneurysm. We’ve seen some pretty bad problems where people have pushed that technology, uh, into that abnormal space. So, I think it’s also really important, I think, people understand how safely we can do these operations.
Everybody’s afraid of having an incision in their chest, and I get that, why wouldn’t you be? But, our outcomes are outstanding, and we just kind of presented all of our annual outcomes recently. They’re pretty great aren’t they?
Dr. Xiaoying Lou: These are the numbers that I cite to the patients. All of the aortic operations that we do and I don’t have the valve data, but I have the root replacement data in elective cases, and they’re like 0.5% mortality is what we use as the major outcome, obviously.
Dr. Eric Roselli: Pretty awesome, right? These patients afterward, they can get back to normal life.
Dr. Xiaoying Lou: Right.
Dr. Eric Roselli: I have patients that are competitive athletes after they go through all this stuff. And, and I think that’s something that people need to appreciate.
And, and that’s one of the beauties of the HeartValveSurgery.com website is it’s patients talking to patients and they share their stories and they reassure each other that, you know, even though this is a scary ordeal, there’s a really good chance you’ll get through it safely and get back to a really high quality of life.
Aortic valve disease and aortic disease which we have a whole bunch of new technology we’ve been working on is certainly making the operations safer and easier to tolerate. But more importantly, providing people good, high quality, lifelong care. We are here to help educate people about that so that patients can make the best decisions for themselves in a precise way with all the options at hand.
