Dilatation of the remaining aorta following
aortic valve or root replacement in patients
with bicuspid aortic valve
Gopal K. R. Soppa, Nada R. Abdulkareem, Siôn Jones,
Oswaldo Valencia, Aiman Alassar, Marjan Jahangiri
Department of Cardiac Surgery,
St George’s Hospital, University of London
Declaration of interest
None
Background
•
Bicuspid aortic valve (BAV) is the
commonest cardiac defect, 1-2%
•
40% association with aortic aneurysm
–
Hemodynamic turbulence theory:
•
•
•
–
Intrinsic aortic wall defect theory:
•
•
•
•
–
Uneven current present (different jet
patterns)
More in aortic root and arch
More in convexity or aorta
BAV aortas have less fibrillin-1,
independent of valve function
Cystic medial necrosis is similar in BAV
and in Marfan syndrome
Aorta continues to dilate post AVR
Aortic aneurysm exist even with normally
functioning BAV
Combination
Evangelista et al; Curr Cardio Rep 2011
McKellar et al; Am J Cardio 2010
Background-Cont.
• Nine times risk of aortic dissection
• Complications occurring a decade younger than
the normal population
• The natural history and management of dilatation
of the aorta in patients with BAV following aortic
valve replacement (AVR) or aortic root
replacement (ARR) remain controversial
Svensson et al; JTCVS 2011
Elefteriades et al; JTCVS 2010
Aim
• To identify dilatation of the remaining aorta
following AVR or ARR in patients with BAV
compared to patients with tricuspid aortic
valve (TAV)
• This can serve as a guide to perform
prophylactic ARR in BAV patients
Methods
• Retrospective analysis, 2002-2009
• n=395, BAV=192 , TAV=203 , AVR and/or ARR
• Serial echocardiograms were studied, median follow-up of 3.8
years (1.2-6.8 years)
– Preoperative, postoperative
– 6 months
– 1, 3, 5 years
• Standard aortic measurements were taken (annulus, STJ,
ascending aorta, aortic arch)
• ARR patients had serial CT scans
• Patients with other connective tissue disorders were excluded
• Ascending aorta diameter ≥4.5cm was regarded aneurysmal
Patient Classification
n= 395
Referred for AVR
or ARR
BAV
+
Normal Aorta
n=143 (36%)
BAV
+
Dilated Aorta
n=49 (12%)
TAV
+
Normal Aorta
n=129 (33%)
TAV
+
Dilated Aorta
n=74 (19%)
Baseline Characteristics
Age (years)
Male
NYHA III/IV
LV Function: Good
Moderate
Poor
Aortic Valve Area (cm2)
Peak Aortic Gradient
(mmHg)
Mean Aortic Gradient
(mmHg)
Aortic Stenosis
Aortic Regurgitation
Aortic Sinus (cm)
Ascending aorta (cm)
BAV
n=143
AA BAV
n=49
TAV
n=129
AA TAV
n=74
57±14
58±12
65±16
67±15
103 (72%)
34 (69%)
81 (63%)
46 (62%)
13 (9%)
5 (10%)
11 (9%)
4 (5%)
74 (51%)
21 (43%)
59 (46%)
37 (50%)
56 (40%)
23 (47%)
56 (43%)
34 (46%)
13 (9%)
5 (10%)
14 (11%)
3 (4%)
0.7 (0.57-0.71) 0.82 (0.68-1.23)
74 ± 12
69 ± 11
43 ± 60
39 ± 60
0.66 (0.50-0.86) 0.9 (0.65-1.30)
83 ± 90
79 ± 90
46 ± 50
47 ± 50
133 (93%)
42 (86%)
125 (97%)
68 (92%)
24 (17%)
13 (27%)
16 (12%)
17 (19%)
3.4 (2.9-3.6)
4.65 (4.38-5)
3.2 (2.8-3.5)
4.2 (3.5-4.9)
3.5 (3-4)
5.05 (4.5-5.8)
3.3 (3.1-3.8) 5.7 (4.88-6.13)
Results-1
Aortic Sinus of Valsalva Dimensions
5.0
***
4.0
***
BAV
BAV+AN
3.0
TAV
TAV+AN
2.0
1.0
pre-op
post-op
1 year
3 years
5 years
Results-2
Ascending Aorta Dimensions
6.0
5.0
BAV
4.0
***
BAV+AN
TAV
3.0
TAV+AN
2.0
1.0
pre-op
post-op
1 year
3 years
5 years
Results-3
Aortic Arch Dimensions
5.0
4.0
BAV
BAV+AN
3.0
TAV
TAV+AN
2.0
1.0
pre-op
post-op
1 year
3 years
5 years
Conclusions
• No significant dilatation of the aorta was
observed following AVR or ARR in
patients with BAV compared with TAV up
to 5 years following surgery
• This supports intervention only with
ascending aorta ≥4.5cm in BAV patients
with concomitant valvular disease