Adult
Long-term outcomes of aortic root procedures for heterogenous ascending aneurysm disease in bicuspid aortic valve syndrome

Read at the 99th Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, May 4-7, 2019.
https://doi.org/10.1016/j.jtcvs.2022.09.068Get rights and content

Abstract

Objective

Surgery for ascending aneurysms in bicuspid aortic valve syndrome primarily includes Bentall root replacement, aortic valve replacement with supracoronary ascending aorta replacement (AVRSCAAR), and valve-sparing root reimplantation (VSRR). Comparative analysis of long-term clinical and functional outcomes of these procedures is detailed.

Methods

From 1997 to 2017, 635 patients with bicuspid aortic valve undergoing root complex-focused procedures electively were stratified by valvulopathy (ie, aortic stenosis vs aortic insufficiency) and substratified into ascending or root aneurysm phenotype. Inverse probability weights were calculated to adjust for baseline differences.

Results

Kaplan-Meier curves for all-cause mortality demonstrated no difference between Bentall versus AVRSCAAR for aortic stenosis and aortic insufficiency presentations (log-rank P > .05). In patients with aortic stenosis, multivariable Cox regression showed significantly decreased risk of stroke for biologic AVRSCAAR (hazard ratio, 0.04; P = .013). Aortic reoperation rates were similar for biologic versus mechanical valves (P = .353).

In patients with aortic insufficiency, similar long-term mortality (hazard ratio, 0.95; P = .93), but lower stroke risk in biologic AVRSCAAR group by Cox regression, and lower aortic reoperation rate was noted (coefficient < 0.01; P < .001). Comparing Bentall to VSRR, mortality (hazard ratio, 0.12; P = .022) was significantly improved in patients undergoing VSRR, but recurrence of moderate or greater aortic insufficiency was higher in VSRR by multistate model (beta coefficient 2.63; P < .001).

Conclusions

A tailored approach to heterogeneous ascending aneurysm pathologies in bicuspid aortic valve syndrome utilizing Bentall, AVRSCAAR, and VSRR procedures renders excellent long-term clinical and functional outcomes, with biologic conduits showing equivalent to improved clinical outcomes.

Section snippets

Methods

Institutional review board approval was obtained (protocol No. 823238; May 2016), and no informed consent was required. An aortic database was retrospectively reviewed to identify patients with BAV undergoing the root complex focused procedures electively: Bentall root replacement, AVRSCAAR, and VSRR.11,12 Patients with genetic and connective tissue disorders, aortic dissection, and emergency cases were excluded. From 1997 to 2017, 635 patients with BAV met inclusion criteria. Patients were

Patients With AS: Bentall Versus AVRSCAAR

A total of 326 out of 635 patients undergoing elective BAV root complex-focused procedures presented with AS or AS + AI mixed valvular disease. Median follow-up for Bentall versus AVRSCAAR was 6.5 years (interquartile range [IQR], 3.3-9.7 years) versus 5.2 years (IQR, 2.6-7.8 years) (P = .003). Total patient-year follow-up in this subgroup was 1941 years. Demographic characteristics and preoperative parameters are detailed in Table 1.

Discussion

Patients with BAV present with a wide and variable spectrum of valvular, ascending, and aortic root aneurysmal pathologies.1, 2, 3 This variability has mandated the development of an array of surgical procedures to tailor an individualized approach to BAV syndrome. Although several centers have reported their experiences with a particular surgical technique in treating BAV root and ascending aortopathies, there are limited long-term clinical and functional data with direct comparative analysis.

Conclusions

The Bentall, AVRSCAAR, and VSRR are excellent aortic root complex-focused procedures for addressing variable aortic valve, aortic root, and ascending aorta pathologies in BAV syndrome. The results of this study may be especially relevant to patients with BAV, who are typically young and may request evidence-based information on long-term functional and clinical outcomes to make an educated decision about repair with valve preservation, and mechanical versus biologic valve conduits.

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    Drs Milewski and Haberteheuer contributed equally to this article.

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