Discussions in Cardiothoracic Treatment and Care
Aortic Valve Repair

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The Tricuspid Aortic Valve

DR. DAVID: Let’s try and limit our discussion for now to the tricuspid aortic valve in a patient aortic root aneurysm as opposed to bicuspid, unicuspid or more complex aortic valve pathology. Craig, Do you ever use remodeling?

DR. MILLER: You and I both went through a phase when we did Yacoub remodeling procedures in the late 1990s and we learned it wasn’t as dependable for patients with root aneurysms, especially those with a connective tissue disorder such as Marfan syndrome or those with

Aortic Root Aneurysm

DR. DAVID: Joe, is there a place for remodeling in aortic root aneurysm?

DR. COSELLI: I agree that there probably is room for remodeling in certain situations, similar to what Lars described. For example, in an older patient where multiple procedures are planned, and they have just a mildly dilated annulus and the leaflets are good, I may just stabilize the annulus and leave it at that. Or, I might bring a “tongue” of graft down to replace the noncoronary sinus. But, if the annulus is really

Repair Competency

DR. DAVID: OK. So the valve is sutured inside the Dacron graft. Now, how can you be sure the valve is competent? Or that there is no cusp prolapse? Gebrine, you start.

DR. EL KHOURY: Now, I do what I call the dynamic assessment: I fill the prosthesis with saline under pressure and we assess the valve. Usually, we have at least one normal leaflet and I really try to take it as a reference and see how the others are too. To see if there is prolapse or not, I use the central stitch, I put a 6-0

Coronary Reimplantation

DR. DAVID: So we have done the reimplantation of a tricuspid valve, the cusps were fairly good or one required a central plication. Now we have to reconnect the coronary arteries. Any trick? The left main seems simple but if you don’t orient it properly you can get into trouble. Want to say anything about left main?

DR. MILLER: I’d like to remind surgeons who do not know there is something we call “The Vail,” that pericardial reflection that comes in above the left main running to the PA. If you

Bicuspid Aortic Valve

DR. DAVID: Let’s move to bicuspid aortic valve now. And start to make things more complicated. The patient is a 50-year old normally functioning bicuspid aortic valve but the ascending aorta is 58 mm and the aortic root 40 mm. What do you do?

DR. EL KHOURY: The patient is 50-year old. The root is normal. The valve is functioning very well. I replace only the ascending aorta with a tube of appropriate size.

DR. DAVID: What size graft?

DR. EL KHOURY: Yes. That’s the problem, the size of the graft. If

Tirone E. David, MD, is a Professor of Surgery at the University of Toronto and the holder of the Melanie Munk Chair of Cardiovascular Surgery at the Peter Munk Cardiac Centre. Doctor David has published 346 scientific papers, 52 chapters in medical textbooks as well as 5 surgical textbooks. He has developed numerous operative procedures to treat patients with heart valve disease, complications of myocardial infarction, and thoracic aneurysms. One of these procedures is known as “David

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Cited by (7)

  • Durability of Aortic Valve Cusp Repair With and Without Annular Support

    2018, Annals of Thoracic Surgery
    Citation Excerpt :

    Incomplete reverse LV remodeling and myocardial fibrosis with diastolic dysfunction is a possible mechanism for this reduced longevity [20]. Cusp repair techniques are still evolving [3, 11, 16, 19, 23]. Figure-of-8 (Svensson) suspension sutures that simultaneously effect commissural plication and resuspension (different from valve resuspension with an aortic graft) were associated with a lower risk of reoperation.

  • Redo Aortic Root Operations in Patients with Marfan Syndrome

    2018, International Journal of Angiology
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Tirone E. David, MD, is a Professor of Surgery at the University of Toronto and the holder of the Melanie Munk Chair of Cardiovascular Surgery at the Peter Munk Cardiac Centre. Doctor David has published 346 scientific papers, 52 chapters in medical textbooks as well as 5 surgical textbooks. He has developed numerous operative procedures to treat patients with heart valve disease, complications of myocardial infarction, and thoracic aneurysms. One of these procedures is known as “David operation.” He has been a member of the editorial board of several medical journals. Doctor David is a member of numerous surgical and medical societies and is honorary member of the European Cardio-Thoracic Association, the Brazilian Cardiovascular Society, Italian Society for Cardiac Surgery, Southern Thoracic Surgical Association, German Society for Thoracic and Cardiovascular, and Society of Cardiac Surgeons. He was President of the American Association for Thoracic Surgery in 2004-2005. He was elected honorary member of the Brazilian National Academy of Medicine in 2013. He received the Order of Ontario in 1993 and the Order of Canada in 1996, the highest honor given to civilians in Canada. He was elected University Professor in 2004, the highest honor the University of Toronto bestows to its professors. (Color version of figure is available online at http://www.semthorcardiovascsurg.com.)

Joseph S. Coselli, MD, Professor and Chief Cullen Foundation Endowed Chair Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX.

Dr Coselli holds the Cullen Foundation Endowed Chair and is Professor and Chief of the Division of Cardiothoracic Surgery at Baylor College of Medicine (BCM). He serves as Chief of Adult Cardiac Surgery at Texas Heart Institute (THI) and Associate Chief of the Cardiovascular Service at Baylor St. Luke’s Medical Center, located in the Texas Medical Center in Houston, Texas. He is also Associate Director of the Thoracic Surgery Residency Program at THI/BCM and directs the Aortic Fellowship Program at Baylor College of Medicine.

Dr Coselli specializes in the evaluation and surgical treatment of diseases of the aorta, and was mentored by the pioneering aortic surgeon, E. Stanley Crawford. A Houston native, he received an introduction to cardiothoracic surgery from Dr Cooley, and as a surgical resident, was instructed by Dr DeBakey; years later, Dr Coselli among others, helped to facilitate a reconciliation between these pioneering giants of their field. He has performed more than 7000 repairs of the aorta and more than 3300 repairs of thoracoabdominal aortic aneurysms, for which he is world renowned. He has published more than 400 medical manuscripts and delivered more than 600 presentations in 27 countries, including the Magistral Lectureship (Brazilian Congress of Vascular Surgery), Magistrale Lectureship (University of Ancona), the Emil T. Hofman Lectureship (University of Notre Dame), the Leriche Lecture (European Society for Cardiovascular Surgery), the Julian Johnson Visiting Lectureship (University of Pennsylvania), the Mary and Wendell Ormston Endowed Lectureship (Robert Wood Johnson Medical School), the Frank Randolph Johnston Lectureship (Wake Forest University), the Hubbard Visiting Professor at Brigham and Women’s Hospital (Harvard Medical School), and the Alfred Blalock Lecture (Johns Hopkins University). In 2008, Dr Coselli was coeditor of the book Aortic Arch Surgery: Principles, Strategies and Outcomes published by Wiley-Blackwell.

Dr Coselli has served as President of the Texas Surgical Society (2008), the Michael E. DeBakey International Surgical Society (2010), the Southern Thoracic Surgical Association (2011), and the Denton A. Cooley Cardiovascular Surgical Society (2012). Currently, he serves as President of the American Association for Thoracic Surgery. Honors include the Antoine Marfan Award (1997) in recognition of outstanding achievement in the field of Marfan syndrome and cardiovascular and aortic valve surgery; the Michael E. DeBakey Excellence in Research Award (2001) for his research on the challenges encountered in the surgical treatment of aortic aneurysms, aortic dissection and Marfan syndrome; physician honoree at the American Heart Association’s Houston Heart Ball (2008); the Ashbel Smith Distinguished Alumnus Award from the University of Texas Medical Branch (2009); Molecular Surgeon Faculty Research Achievement Award (2009) from the Michael E. DeBakey Department of Surgery, Baylor College of Medicine; the Scientific Leadership Award (2010) for his work on the Aortic Valve Operative Study from the National Marfan Foundation; and along with colleague Scott A. LeMaire, the Distinguished Scientist Award (2011) from St. Luke’s Episcopal Hospital; the inaugural Francis R. Robicsek Award from the Sanger Heart & Vascular Institute (2014); the twenty-fifth annual John W. Kirklin Named Visiting Professor in Cardiac Surgery and Related Problems from the Mayo Clinic (2014); and the Inaugural Randall B. Griepp Visiting Professorship from Icahn School of Medicine at Mount Sinai (2015). Additional honors for scientific papers include the J. Maxwell Chamberlain Memorial Paper by the Society of Thoracic Surgeons (2001), the President’s Award (2002) from the Southern Thoracic Surgical Association, and best scientific paper (2004) of the Peripheral Vascular Surgical Society. (Color version of figure is available online at http://www.semthorcardiovascsurg.com.)

Gebrine El Khoury, MD, left Lebanon to arrive in Belgium when he was 18 years old.

He started his medical school at the University Catholic of Louvain in 1977 to finish in 1984 (cum Maxima Laude).

He got married in August 1992 with Sylvie Lepièce (gynaecological surgeon). They have 4 children (Marie, Antoine, Pauline, and Leila).

He joined in September 1996 the Cliniques Universitaires Saint-Luc (Brussels—Belgium) as Associated Professor in the Department of Cardiovascular and Thoracic Surgery—Catholic University of Louvain.

He is head or the Cardiovascular and Thoracic Surgery Department since 2004.

Gebrine El Khoury, MD, PhD, is recognised as a pioneer in aortic-valve repair.

He and his team run what has become a key centre in the treatment of valve disease; the centre is now considered a true authority on cardiac surgery, as illustrated by its many daily visitors, its active involvement in high-level international conferences (live surgery, lectures, postgraduate courses, etc.) and the organisation of three international meetings each year. (Color version of figure is available online at http://www.semthorcardiovascsurg.com.)

D. Craig Miller, MD, is the Thelma and Henry Doelger Professor of Cardiovascular

Surgery at the Stanford University School of Medicine. He is a past-president of the American

Association for Thoracic Surgery and the Western Thoracic Surgical Association, and former chairman of the American Heart Association’s Cardiovascular Surgery Council. Dr Miller is responsible for major advances in the understanding and treatment of mitral and aortic valve disease, thoracic aortic diseases, heart physiology, and cardiac mechanics. (Color version of figure is available online at http://www.semthorcardiovascsurg.com.)

Lars G. Svensson, MD, PhD, is Chairman of the Sydell and Arnold Miller Family Heart and Vascular Institute as well as Staff Surgeon in the Department of Thoracic and Cardiovascular Surgery at Cleveland Clinic. He is also Professor of Surgery at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Dr Svensson is board-certified in general, vascular, thoracic and cardiac surgery. He specializes in aortic valve surgery, aortic valve and bicuspid valve repair, cardiac surgery, complex aortic aneurysm, endovascular aorta treatment, heart surgery of patients with Marfan syndrome, modified David’s reimplantation procedure, percutaneous treatment of patients with valve disease, minimally invasive heart surgery, Marfan syndrome and connective tissue disorders. He obtained his medical degree in 1978, a MSc in 1983 and a PhD in 1986 from the University of Witwatersrand, Johannesburg, South Africa. His Cardiology, General and Vascular Surgery training was at the Johannesburg Hospital, followed by Cardiovascular Surgery training at the Cleveland Clinic (Cleveland, Ohio), and Baylor College of Medicine (Houston, TX) including Cardiothoracic Surgery residency. He was Chief of Cardiovascular Surgery at Houston Veterans Affairs Medical Center and worked with Drs. DeBakey and Crawford at Baylor College of Medicine. He was Assistant Professor of Surgery at Baylor College of Medicine, and then Professor of Cardiothoracic Surgery at Tufts University, and Instructor at Harvard Medical School while working at the Lahey Hospital and Medical Center in Boston. In 2005, he was made King James IV Professor of Surgery of The Royal College of Surgeons of Edinburgh, Scotland. He is on numerous committees, including the Society of Thoracic Surgery, American Association for Thoracic Surgery Government Relations Committee, Annals of Thoracic Surgery, and the Cleveland Clinic Surgery Committee. His interests are minimal invasive valve surgery, percutaneous cardiovascular surgery, and brain and spinal cord protection during cardiovascular surgery. His hobbies are photography and sailing. (Color version of figure is available online at http://www.semthorcardiovascsurg.com.)

Disclosures: Dr. Coselli reports personal fees from St. Jude Medical, Inc.; grants, personal fees and other from Vascutek Ltd., a Terumo Company; other from Edwards Lifesciences; personal fees and other from Medtronic, Inc. All are outside the submitted work.

Dr. Miller reports grants from Abbott Vascular, personal fees from GenTAC Scientific Oversight Advisory Board, NHLB Contract to RTI, personal fees from Medtronic Inc, grants from Medtronic Inc, grants from Edwards Lifesciences, LLC, non-financial support from PARTNER Exec Committee, Percutaneous AVR, Edwards Lifesciences, LLC, grants from Edwards Lifesciences, LLC, outside the submitted work.

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