Dilatation of the remaining aorta following aortic valve or root replacement in patients with bicuspid aortic valve

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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 Georges Hospital, University of London
• Declaration of interest
• None

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Background

• Bicuspid aortic valve (BAV) is the commonest
  cardiac defect, 1-2
• 40 association with aortic aneurysm
• Hemodynamic turbulence theory
• Uneven current present (different jet patterns)
• More in aortic root and arch
• More in convexity or aorta
• Intrinsic aortic wall defect theory
• 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
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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
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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

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Methods

• Retrospective analysis, 2002-2009
• n395, BAV192 , TAV203 , 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

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Patient Classification
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Baseline Characteristics
BAV n143 AA BAV n49 TAV n129 AA TAV n74
Age (years) 5714 5812 6516 6715
Male 103 (72) 34 (69) 81 (63) 46 (62)
NYHA III/IV 13 (9) 5 (10) 11 (9) 4 (5)
LV Function Good 74 (51) 21 (43) 59 (46) 37 (50)
Moderate 56 (40) 23 (47) 56 (43) 34 (46)
Poor 13 (9) 5 (10) 14 (11) 3 (4)
Aortic Valve Area (cm2) 0.7 (0.57-0.71) 0.82 (0.68-1.23) 0.66 (0.50-0.86) 0.9 (0.65-1.30)
Peak Aortic Gradient (mmHg) 74 12 69 11 83 90 79 90
Mean Aortic Gradient (mmHg) 43 60 39 60 46 50 47 50
Aortic Stenosis 133 (93) 42 (86) 125 (97) 68 (92)
Aortic Regurgitation 24 (17) 13 (27) 16 (12) 17 (19)
Aortic Sinus (cm) 3.4 (2.9-3.6) 4.65 (4.38-5) 3.2 (2.8-3.5) 4.2 (3.5-4.9)
Ascending aorta (cm) 3.5 (3-4) 5.05 (4.5-5.8) 3.3 (3.1-3.8) 5.7 (4.88-6.13)
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Results-1
Aortic Sinus of Valsalva Dimensions


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Results-2
Ascending Aorta Dimensions

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Results-3
Aortic Arch Dimensions
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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