Dilatation of the Remaining Aorta After Aortic Valve or Aortic Root Replacement in Patients With Bicuspid Aortic Valve: A 5-Year Follow-Up

doi:10.1016/j.athoracsur.2013.03.086

The Annals of Thoracic Surgery

Volume 96, Issue 1, July 2013, Pages 43-49

https://doi.org/10.1016/j.athoracsur.2013.03.086 Get rights and content

Background

The natural history and management of ascending aorta (AA) and arch dilatation in patients with bicuspid aortic valve (BAV) after aortic valve replacement (AVR) or aortic root replacement (ARR) remains controversial. Our aim is to identify dilatation of the remaining aorta after AVR or ARR in patients with BAV compared with patients with tricuspid aortic valve (TAV).

Methods

Three hundred ninety-five patients who underwent AVR or ARR between 2002 and 2009 were studied. Preoperative computed tomography (CT) and echocardiography were performed in 192 patients with BAV, and the results were compared with those of 203 patients with TAV. An AA diameter 4.5 cm or greater was regarded as aneurysmal. Postoperative echocardiograms, computed tomographic scans, and magnetic resonance images were compared with subsequent imaging at a median follow-up of 4.6 years (2.2–9.8 years).

Result

Median ages of patients with BAV and patients with TAV were 57 ± 14 and 65 ± 16 years, respectively (p < 0.05). Preoperative diameter of AA in the BAV group with no aneurysm (3.5 cm; range, 3.0–4.0 cm; n = 143) was significantly higher than in the TAV group (3.3 cm; range, 3.1–3.8 cm; n = 129) (p < 0.001). In both BAV and TAV groups with nonaneurysmal aortas who underwent AVR, there was no significant expansion of the AA and arch at 5 years' follow-up. In patients with aneurysmal aorta (BAV group, n = 49; TAV group, n = 74) who underwent ARR, there was also no significant difference in growth of the remaining aorta at 3 and 5 years' follow-up.

Conclusions

No significant dilatation of the AA or arch was observed after AVR or ARR, respectively, in patients when a cut-off diameter of 4.5 cm or greater was considered for replacement in patients with BAV compared with patients with TAV up to 5 years after operation. The need for aortic replacement at smaller diameters was not found.

Section snippets

Study Design

From January 2002 to December 2009, 395 consecutive patients who were operated on under the care of 1 surgeon and underwent AVR or ARR, or both, were studied. Patients with known connective tissue disorders, eg, Marfan's syndrome, were excluded from the study. Familial screening was not systematically performed when familial aortopathies existed; however, those patients were not excluded from the study. Younger patients with functionally normal BAVs underwent valve-preserving procedures and

Results

From a total of 395 patients, 203 had TAV and 192 had BAV. In the BAV group, 12 patients had AVR with supracoronary AA replacement and 37 patients had ARR. In the TAV group, 49 patients had AVR with supracoronary AA replacement and 25 had ARR (Fig 1). Concomitant coronary artery bypass grafting (CABG) was performed in 36 (25%) patients with BAV, 4 patients (8.2%) with BAV and aortic aneurysm (AA-BAV), 70 (54.2%) patients with TAV, and 10 (13.5%) patients with TAV and aortic aneurysm (AA-TAV).

Comment

In this study, patients with BAV and an AA absolute diameter of 4.5 cm or greater and a dilated root underwent ARR. This was a uniform policy. We have shown that there was no significant difference in morbidity and mortality comparing AVR with ARR in patients with BAV and that no patient with an aortic diameter of less than 4.5 cm required operation for dissection or resection of aneurysm during follow-up. Also, no patient required surgical intervention for the arch.

These findings concur with

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Cited by (32)

Does the Leaflet Fusion Subtype Affect Pattern and Rate of Growth in BAV Aortopathy?: A Study of 102 BAV Aortopathy Cases With A Literature Review
2021, Heart Lung and Circulation
Citation Excerpt :
Aortic pathology including confirmation of aortic diameters and dilatation patterns, and details of surgical procedure were recorded. Special note was made of type of valve [17] and Sievers’ types [7] in case of BAV (Figure 2). All 102 patients had at least two consecutive CT aortograms, minimum 1 year apart, which were used to calculate aortic growth.
Bicuspid aortic valves (BAV) and related aortopathy remain an intriguing topic. Not all BAVs get diseased and around 40% would develop aortic dilatation in their lifetime. If haemodynamic theory is to be believed, then leaflet fusion pattern should have an impact. This study sought to compare the association of aortic morphologies and rate of growth in a set of 102 BAV acropathies operated at a single centre, based on the fusion patterns.
Data on aortic valve replacements over a 10-year period was analysed from a prospectively maintained database. Of the 198 BAV undergoing surgery, 102 had aortic dilatation above 40 mm on echocardiogram. These underwent computed tomography (CT) aortograms and were followed up as a part of a database. The impact of leaflet fusion patterns on aortic dilatation pattern and rate was analysed.
Of the 102, two patients had type 0 pathology and one had left-noncoronary (LN) leaflet fusion. Seventy-four (74) had type 1A or left-right (RL) fusion and 25 had type 1B right-noncoronary (RN) fusion. RL fusion had more males, were taller, bigger and had more proportion of aortic stenosis (AS). Aortic diameters, angles and growth rates at root, ascending/descending aorta and arch were not different. Regression analyses for size or growth did not show any significant impact of fusion pattern.
Left-right fusion pattern comprised three-quarters of BAV in this cohort and these patients were bigger, taller and had a greater proportion of males with increased rate of aortic stenosis. Despite these differences, there was no significant impact of fusion pattern on aortic size or rate of growth.
Commentary: In the absence of convincing evidence, more is not better
2021, JTCVS Open
Should all patients with aortic aneurysm and bicuspid aortic valve also undergo hemiarch?
2021, JTCVS Open
Long-term Fate of Dilated Ascending Aorta after Aortic Valve Replacement for Bicuspid Versus Tricuspid Aortic Valve Disease
2020, American Journal of Cardiology
We compared the long-term outcomes and difference in dilatation rates of the ascending aorta after aortic valve (AV) replacement (AVR) between bicuspid and tricuspid AV patients, and evaluated risk factors associated with ascending aorta dilatation and aortic events during the follow-up. Of 1,127 patients who underwent AVR from 1995 to 2015, 259 patients with a dilated ascending aorta (≥40 mm in diameter) were included. The patients were divided into those with bicuspid (group bicuspid aortic valve [BAV], n = 105) and with tricuspid (group tricuspid aortic valve [TAV], n = 154) AV, and a propensity score-matched analysis was performed to match 98 patients in each group. The differences in the dilation rate of the ascending aorta and long-term outcomes were analyzed. Risk factors for ascending aorta dilatation, mortality, and aortic events were identified. Follow-up was completed in 100% of patients with a median follow-up duration of 106.1 [68.8, 163.0] months. The early clinical outcomes and dilation rate of the ascending aorta were similar between the groups. Overall survivals up to 15 years postoperatively were similar between groups BAV and TAV (p = 0.223). Aortic events occurred in 6 patients (groups BAV vs TAV, 2 vs 4;p = 0.678). Preoperative ascending aorta diameter showed a linear relationship with the dilatation rate of ascending aorta (p <0.001) and was related to progressive aortic dilatation and aortic events (odds ratio: 1.25, p <0.001 and hazard ratio = 1.56, p <0.001, respectively). In conclusion, the long-term outcomes and ascending aorta dilatation rate were similar between the BAV and TAV patients up to 15 years after AVR. Bicuspid AV was not a risk factor of mortality or aortic events.
Commentary: To be or not to be: The guidelines are the question
2019, Journal of Thoracic and Cardiovascular Surgery
The aortic root does not dilate over time after replacement of the aortic valve and ascending aorta in patients with bicuspid or tricuspid aortic valves
2018, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Although guidelines have recently increased the size threshold for prophylactic aortic repair in BAV,13-15 some groups advocate for aggressive replacement of the aortic root and proximal arch in patients with BAV who present with aortic valve disease and aneurysms limited to the ascending aorta.16-18 Conversely, other studies show no dilatation of the aortic root or ascending aorta after AVR in patients with BAV compared with patients with TAV or the general population.19-21 Itagaki et al showed that patients with BAV develop significantly less aortic dilatation after AVR compared with patients with Marfan syndrome.22
Whether the aortopathy associated with bicuspid aortic valve (BAV) disease occurs secondary to genetic or hemodynamic factors remains controversial. In this article we describe the natural history of the aortic root in patients with bicuspid versus tricuspid aortic valves (TAVs) after replacement of the aortic valve and ascending aorta.
From 1990 to 2010, 406 patients (269 BAV, 137 TAV) underwent aortic valve and ascending aorta replacement at a single institution. Patients with aortic dissection, endocarditis, previous aortic surgery, or Marfan syndrome were excluded. All available follow-up imaging was reviewed.
Mean imaging follow-up was 5.5 (±5.3) years. Of all patients, 66.5% had at least 1 aortic root measurement after the index operation. Baseline aortic diameter was comparable between groups. In patients with BAV, aortic root diameter increased at a clinically negligible rate over time (0.654 mm per year; 95% confidence interval, 0.291-1.016; P < .001), similar to patients with TAV (P = .92). Mean clinical follow-up was 8.1 (±5.4) years. During follow-up, 18 patients underwent reoperation, 89% for a degenerated bioprosthetic aortic valve. Only 1 patient underwent reoperation for a primary indication of aortic aneurysmal disease, 22 years after the index operation. There were no differences in cumulative incidence rates of aortic reoperation (P = .14) between patients with BAV and TAV.
Mid-term imaging after aortic valve and ascending aorta replacement indicates that if the aortic root is not dilated at the time of surgery, the risk of enlargement over time is minimal, negating the need for prophylactic root replacement in patients with BAV or TAV.

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Original articleAdult cardiacDilatation of the Remaining Aorta After Aortic Valve or Aortic Root Replacement in Patients With Bicuspid Aortic Valve: A 5-Year Follow-Up

Background

Methods

Result

Conclusions

Section snippets

Study Design

Results

Comment

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Thorac Cardiovasc Surg

Semin Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Failure to prevent progressive dilation of ascending aorta by aortic valve replacement in patients with bicuspid aortic valve: comparison with tricuspid aortic valve

Circulation

Ascending aortic dilatation associated with bicuspid aortic valve: pathophysiology, molecular biology, and clinical implications

Circulation

Original article
Adult cardiac
Dilatation of the Remaining Aorta After Aortic Valve or Aortic Root Replacement in Patients With Bicuspid Aortic Valve: A 5-Year Follow-Up