Risk of late aortic events after an isolated aortic valve replacement for bicuspid aortic valve stenosis with concomitant ascending aortic dilation.
ABSTRACT The optimal surgical treatment of patients with bicuspid aortic valve (BAV) disease and ascending aortic aneurysm is controversial. The aim of this study was to evaluate the risk of late aortic events after an isolated aortic valve replacement (AVR) for BAV stenosis with concomitant mild-to-moderate proximal aortic dilation.
A review of our institutional BAV database identified a subgroup of 153 consecutive BAV patients (mean age 54.2 ± 10.5 years, 73% men) with BAV stenosis and concomitant ascending aortic dilation of 40-50 mm who underwent an isolated AVR from 1995 to 2000. All cases of simultaneous aortic surgery (i.e. ascending aorta with a diameter of >50 mm) were excluded. The follow-up (1759 patient-years) was 100% complete. The mean follow-up was 11.5 ± 3.2 years. Adverse aortic events were defined as the need for proximal aortic surgery, the occurrence of aortic dissection/rupture or sudden death during the follow-up.
Actuarial survival rates of our study population were 86 and 78% at 10 and 15 years, respectively. Ascending aortic surgery was required in five patients (3%) for progressive ascending aortic aneurysm. Freedom from aortic interventions at 10 and 15 years was 97 and 94%, respectively. No documented aortic dissection or rupture occurred. Freedom from adverse aortic events was 95% at 10 years and 93% at 15 years postoperatively. In a separate group of patients presenting with aortic insufficiency (i.e. root phenotype), freedom from adverse aortic events was significantly lower (88 and 70% at 10 and 15 years, P = 0.009).
BAV patients with aortic valve stenosis and concomitant mild-to-moderate ascending aortic dilation are at a considerably low risk of adverse aortic events at 15 years after an isolated AVR. The BAV phenotype should be considered when determining the risk of subsequent adverse aortic events and the need for concomitant aortic replacement.
Article: Reply to Dayan et al.European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 02/2013; · 2.40 Impact Factor
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ABSTRACT: The purpose of this study was to analyse the correlation between preoperative systolic transvalvular flow patterns and proximal aortic wall lesions in patients undergoing surgery for bicuspid aortic valve (BAV) stenosis. A total of 48 consecutive patients with BAV stenosis (mean age 58 ± 9 years, 65% male) underwent aortic valve replacement (AVR) ± proximal aortic surgery from January 2012 through February 2013. Preoperative cardiac phase-contrast cine magnetic resonance imaging (MRI) assessment was performed in all patients in order to detect the area of maximal flow-induced stress in the proximal aorta. Based on these MRI data, two aortic wall samples (i.e. area of the maximal stress (jet sample) and the opposite aortic wall (control sample)) were collected during AVR surgery. Aortic wall changes were graded based on a summation of seven histological criteria (each scored from 0 to 3). Histological sum score (0-21) was separately calculated and compared between the two aortic samples (i.e. jet sample vs control sample). An eccentric transvalvular flow jet hitting the proximal aortic wall could be identified in all 48 (100%) patients. The mean histological sum score was significantly higher in the jet sample vs control sample areas of the aorta (i.e. 4.1 ± 1.8 vs 2.2 ± 1.5, respectively) (P = 0.02). None of the patients had a higher sum score value in the control sample. Our study demonstrates a strong correlation between the systolic pattern of the transvalvular flow jet and asymmetric proximal aortic wall changes in patients undergoing AVR for BAV stenosis.European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 01/2014; · 2.40 Impact Factor
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ABSTRACT: Bicuspid aortic valve (BAV) is the most common form of congenital heart disease and most such patients develop cardiovascular complications over time. Recent studies have shed light on one of the most common of these complications, BAV-associated aortopathy. Two distinct BAV phenotypes have been identified, which may have different causes of their associated aortopathy. Increasing evidence suggests that the BAV stenosis phenotype is predominantly secondary to hemodynamic perturbances in transvalvular flow and is associated with a more benign long-term prognosis once the stenotic BAV is replaced. In contrast, the root phenotype-which is associated with aortic insufficiency-appears to have a genetic origin and may be associated with a higher risk of adverse aortic complications, irrespective of the extent of valvular disease. Such observations may have implications for patient decision making. Future studies should be performed so as to better define phenotypes and risk factors for BAV-associated aortopathy.Seminars in Thoracic and Cardiovascular Surgery 01/2013; 25(4):310-6.