P068. Bicuspid Aortopathy: Is a Lower Size Threshold for Elective Repair Justified?
Presented During: POD Abstracts (Available for viewing in the exhibit hall for the duration of the meeting)
Emory University School of Medicine
Atlanta, GA
United States - Contact Me
Elizabeth Norton, MD is an integrated cardiothoracic surgery resident at Emory University.
Thursday, April 25, 2024: 5:38 PM - 7:00 PM
Sheraton Times Square
Room: Central Park
Description
Objective: Bicuspid aortic valve occurs in 1-2% of the population and has been associated with aortopathy in addition to valve pathology. Guidelines regarding surgical management of bicuspid aortopathy has remained controversial with some advocating for surgical intervention earlier compared to those with tricuspid aortic valves due to an increase risk of dissection in the BAV patient. The purpose of this study is to characterize the indications and incidence of aortic dissection in BAV patients.
Methods: Over four years, 634 patients underwent either an aortic root and/or ascending replacement at a single institution. Patients were stratified based on aortic valve morphology to bicuspid aortic valve (BAV, n=190) or tricuspid aortic valve (TAV, n=444) groups. Further analysis was performed of the BAV group based on aortic indication (aneurysm vs dissection). Data was obtained from the institutional STS Adult Cardiac Surgery database and supplemented with medical record review.
Results: Patients with BAVs comprised 30% of all patients undergoing aortic root and/or ascending replacement. Patients with BAVs were younger (56 vs 61 years, p<0.0001) and had less comorbidities including hypertension, stroke, myocardial infarction, and less prior cardiac surgery. Moderate-to-severe aortic insufficiency was similar between BAV and TAV groups, while the BAV group had significantly more moderate-to-severe aortic stenosis. The primary indication for surgery differed significantly between BAV and TAV groups with the BAV group having more operations for primary valve pathology (BAV 20% vs TAV 8%, p< 0.05) while the TAV group had more operations for primary aortic pathology (BAV 51% vs TAV 72%, p< 0.05). Among the aortic indication for root/ascending replacement, the BAV group had significantly more elective cases for thoracic aortic aneurysm vs urgent/emergent cases for aortic dissections compared to the TAV group. Only 5.8% (11/190) of the BAV group had surgery for a type A aortic dissection compared to 40% (176/444) of the TAV group (p<0.0001). The BAV group did undergo surgery at smaller thoracic aortic diameters compared to the TAV group (50 vs 52 mm, p=0.001). Postoperatively, patients with BAV had better postoperative outcomes including lower in-hospital mortality (3.2% vs 7.7%, p=0.03) compared to patients with TAVs. Among BAVs, patients undergoing surgery for a type A aortic dissection had worse outcomes than those for a thoracic aortic aneurysm, including higher in-hospital mortality (27% vs 2%, p=0.003). Long-term survival was greater among the BAV group compared to the TAV group (12-year: 81% [69%, 88%] vs 58% [47%, 68%].
Conclusions: Despite only representing 1-2% of the population, patients with bicuspid aortic valves comprise almost one-third of patients undergoing root/ascending aortic replacement in a high-volume aortic center, and rarely present with acute aortic dissection. These data suggest that BAV aortopathy may not be more prone to aortic dissection than TAV patients, and do not require a lower size threshold for surgical intervention.
Authors
Elizabeth Norton (1), Ryon Arrington (2), Alan Amedi (2), Woodrow Farrington (2), Brent Keeling (2), Bradley Leshnower (3)
Institutions
(1) Emory University, Atlanta, GA, (2) Emory University School of Medicine, Atlanta, GA, (3) Emory University Hospital, Atlanta, GA
Methods: Over four years, 634 patients underwent either an aortic root and/or ascending replacement at a single institution. Patients were stratified based on aortic valve morphology to bicuspid aortic valve (BAV, n=190) or tricuspid aortic valve (TAV, n=444) groups. Further analysis was performed of the BAV group based on aortic indication (aneurysm vs dissection). Data was obtained from the institutional STS Adult Cardiac Surgery database and supplemented with medical record review.
Results: Patients with BAVs comprised 30% of all patients undergoing aortic root and/or ascending replacement. Patients with BAVs were younger (56 vs 61 years, p<0.0001) and had less comorbidities including hypertension, stroke, myocardial infarction, and less prior cardiac surgery. Moderate-to-severe aortic insufficiency was similar between BAV and TAV groups, while the BAV group had significantly more moderate-to-severe aortic stenosis. The primary indication for surgery differed significantly between BAV and TAV groups with the BAV group having more operations for primary valve pathology (BAV 20% vs TAV 8%, p< 0.05) while the TAV group had more operations for primary aortic pathology (BAV 51% vs TAV 72%, p< 0.05). Among the aortic indication for root/ascending replacement, the BAV group had significantly more elective cases for thoracic aortic aneurysm vs urgent/emergent cases for aortic dissections compared to the TAV group. Only 5.8% (11/190) of the BAV group had surgery for a type A aortic dissection compared to 40% (176/444) of the TAV group (p<0.0001). The BAV group did undergo surgery at smaller thoracic aortic diameters compared to the TAV group (50 vs 52 mm, p=0.001). Postoperatively, patients with BAV had better postoperative outcomes including lower in-hospital mortality (3.2% vs 7.7%, p=0.03) compared to patients with TAVs. Among BAVs, patients undergoing surgery for a type A aortic dissection had worse outcomes than those for a thoracic aortic aneurysm, including higher in-hospital mortality (27% vs 2%, p=0.003). Long-term survival was greater among the BAV group compared to the TAV group (12-year: 81% [69%, 88%] vs 58% [47%, 68%].
Conclusions: Despite only representing 1-2% of the population, patients with bicuspid aortic valves comprise almost one-third of patients undergoing root/ascending aortic replacement in a high-volume aortic center, and rarely present with acute aortic dissection. These data suggest that BAV aortopathy may not be more prone to aortic dissection than TAV patients, and do not require a lower size threshold for surgical intervention.
Authors
Elizabeth Norton (1), Ryon Arrington (2), Alan Amedi (2), Woodrow Farrington (2), Brent Keeling (2), Bradley Leshnower (3)
Institutions
(1) Emory University, Atlanta, GA, (2) Emory University School of Medicine, Atlanta, GA, (3) Emory University Hospital, Atlanta, GA
Presentation Duration
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