Effect of Ascending Aortic Replacement on Long-term Outcomes of Bicuspid Aortic Valve Repair
Lars G. Svensson, Kyle Miletic, Brad Rosinski, Kevin Hodges, Jeevanantham Rajeswaran, Brian Griffin, Milind Desai, Vidyasagar Kalahasti, Douglas R. Johnston, Eric E. Roselli, Eugene Blackstone
Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, United States
Objective: Patients with bicuspid aortic valve (BAV) regurgitation who undergo valve repair often present with ascending aortic dilation. Although debate continues as to the etiology of BAV-associated aneurysms, it remains unclear whether concomitant ascending aorta replacement improves long-term BAV repair durability by stabilizing the sinotubular junction and avoiding late dilatation. Objective was to determine the effect concomitant ascending aorta replacement had on long-term outcomes after BAV repair.
Methods: From 1/1998 to 1/2020, 421 patients had BAV repair alone (BAVr alone) and 421 BAV repair with ascending aorta replacement (BAVr + asc). Longitudinal echocardiographic trajectories were characterized and compared using mixed-effect cumulative logit regression. Propensity-score matching was performed to compare outcomes, yielding 88 matched pairs. Preoperative variables after matching were similar between BAVr alone vs BAVr + asc, including percent of patients with moderate to severe aortic regurgitation (AR) (54% vs 56%) and mild AR (36% vs 31%).
Results: In the matched cohorts, there was 1 in-hospital death after BAVr alone and none after BAVr + asc. Matched ten-year survival was 87% for BAVr alone and 95% for BAVr + asc (P=.08). Ten-year prevalence of severe AR was 5% for BAVr alone and 11% for BAVr + asc (P>.2). Overall, there were 136 aortic valve reoperations. Indications included aortic stenosis secondary to late cusp calcification (n=53, 39%), late AR secondary to cusp degeneration (n=34, 25%) or aortic root dilation (n=20, 15%), early repair failure (n=27, 20%), and endocarditis (n=2, 1.4%). Before matching, there was an early higher risk of reoperation after BAVr alone compared to BAVr + asc (P=.01), particularly early in the experience when concomitant ascending aorta replacement was less common. However, risk of reoperation was similar between the groups after 1 year (P=.8). Ten-year freedom from reoperation for late aortic stenosis was comparable between BAVr alone (93%) and BAVr + asc (87%, P=.08). Ten-year freedom from reoperation for late AR was also similar between BAVr alone (91%) and BAVr + asc (92%, P=.8), including reoperations for AR secondary to root dilation (BAVr alone: 97% vs BAVr + asc: 96%, P=.4). After matching, overall 10-year freedom from reoperation was similar between BAVr alone (84%) and BAVr + asc (80%, P=.08).
Conclusion: BAV repair with or without ascending aorta replacement is associated with good short- and long-term outcomes. Stabilization of the sinotubular junction with concomitant ascending aorta replacement does not appear to influence long-term valve durability. Ascending aorta replacement should be offered as a concomitant procedure when the ascending diameter meets current guidelines for replacement and should not be performed for the sole purpose of long-term BAV repair durability.
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