Valve structure and survival in septuagenarians having aortic valve replacement for aortic stenosis (+/-aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005)

Impact of Valve Morphology on the Prevalence of Coronary Artery Disease: A Systematic Review and Meta-Analysis

Background

Literature studies suggested a lower prevalence of coronary artery disease (CAD) in bicuspid aortic valve (BAV) than in tricuspid aortic valve (TAV) patients. However, this finding has been challenged. We performed a meta‐analysis to assess whether aortic valve morphology has a different association with CAD, concomitant coronary artery bypass grafting (CABG), and postoperative mortality.

Methods and Results

Detailed search was conducted according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta‐Analyses) guideline to identify all patients with BAV or TAV and presence of CAD, concomitant myocardial surgical revascularization, and the postoperative mortality. Thirty‐one studies on 3017 BAV and 4586 TAV patients undergoing aortic valve surgery were included. BAV patients showed a lower prevalence of CAD (odds ratio [OR]: 0.33; 95% CI: 0.17, 0.65), concomitant CABG (OR, 0.45; 95% CI: 0.35, 0.59), and postoperative mortality (OR, 0.62; 95% CI: 0.40, 0.97) than TAV. However, BAV subjects were significantly younger than TAV (mean difference: −7.29; 95% CI: −11.17, −3.41) were more frequently males (OR, 1.61; 95% CI: 1.33, 1.94) and exhibited a lower prevalence of hypertension (OR, 0.58; 95% CI: 0.39, 0.87) and diabetes (OR, 0.71; 95% CI: 0.54, 0.93). Interestingly, a metaregression analysis showed that younger age and lower prevalence of diabetes were associated with lower prevalence of CAD (Z value: −3.03; P=0.002 and Z value: −3.10; P=0.002, respectively) and CABG (Z value: −2.69; P=0.007 and Z value: −3.36; P=0.001, respectively) documented in BAV patients.

Conclusions

Analysis of raw data suggested an association of aortic valve morphology with prevalence of CAD, concomitant CABG, and postoperative mortality. Interestingly, the differences in age and diabetes have a profound impact on prevalence of CAD between BAV and TAV. In conclusion, our meta‐analysis suggests that the presence of CAD is independent of aortic valve morphology.

Natural history of adults with congenitally malformed aortic valves (unicuspid or bicuspid)

Appreciation of the frequency of the congenitally malformed aortic valve has come about during the last 50 years, a period during which aortic valve replacement became a predictably successful operation. Study of patients at necropsy with either a congenitally unicuspid (1 true commissure) or bicuspid (2 true commissures) valve in whom no aortic valve operation has been performed has not been conducted during these 50 years, to our knowledge. We studied 218 patients at necropsy with congenitally malformed aortic valves: 28 (13%) had a unicuspid valve and 190 (87%), a bicuspid valve. Their ages at death ranged from 21 to 89 years (mean, 55 yr), and 80% were men. Of the 218 adults, the aortic valve functioned normally during life in 54 (25%) and abnormally in 164 (75%): aortic stenosis in 142 (65%), pure aortic regurgitation without superimposed infective endocarditis (IE) in 2 (1%), and IE superimposed on a previously normally functioning aortic valve in 20 (9%). IE occurred in a total of 31 (14%) of the 218 patients: involving a previously normally functioning valve in 20 (65%) and a previously stenotic valve in 11 (35%). Of the 218 patients, at least 141 (65%) died as a consequence of aortic valve disease (124 patients) or ascending aortic tears with or without dissection (17 patients). An estimated 1% of the population, maybe higher in men, has a congenitally malformed aortic valve. Data from this study suggest that about 75% of them will develop a major complication. Conversely, and encouragingly, about 25% will go through life without a complication.

The role of echocardiography in the evaluation and management of aortic stenosis in the older adult

Aortic stenosis is currently the most predominant valvular pathology in older adults. Signs and symptoms of aortic stenosis in this age-group may be difficult to recognize due to the decreased activity associated with aging and attribution of symptoms to other conditions. Echocardiography can be very helpful in the assessment of valvular structure and real time hemodynamic evaluation as well as in the progression of the disease over time. Unprecedented advances in echocardiography, including real time three-dimensional echocardiography, facilitate a comprehensive assessment of this condition and help in the decision-making process. Recent innovations in the percutaneous treatment of valvular diseases promise a revolution in the treatment of aortic stenosis especially in older adults.

Valve structure and survival in quadragenarians having aortic valve replacement for aortic stenosis (+/-aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005)

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and the influence of valve structure on both early and late survival in quadragenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). We analyzed survival and valve structure in 48 adults (12 women), aged 40 to 49 years, having AVR for AS from 1993 through 2005 at Baylor University Medical Center, including 7 (15%) with and 41 (85%) without simultaneous CABG. Of the 48 quadragenarians, none died within 60 days of operation. Assessment of the relation between long-term survival and gender, aortic valve structure, preoperative severity of the AS, and concomitant CABG was not possible due to the low mortality. Four patients (9%) died >60 days after AVR: at 1.8, 6.3, 7.1, and 9.9 years, respectively. The aortic valve was congenitally unicuspid in 15 patients (31%), congenitally bicuspid in 32 (67%), and 3-cuspid in 1 (2%). In conclusion, of the 48 quadragenarians having AVR for AS, 47 (98%) had a congenitally malformed aortic valve, 60-day mortality was zero, and late mortality was low (8%).

Valve structure and survival in quinquagenarians having aortic valve replacement for aortic stenosis (+/-aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005)

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and the influence of valve structure on both early and late survival in quinquagenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). We analyzed survival and valve structure in 120 quinquagenarians having AVR for AS from 1993 through 2005 at Baylor University Medical Center, including 44 (37%) with and 76 (63%) without simultaneous CABG. Of the 120 patients, 2 (2%) died within 30 days of operation and none from 31 to 60 days postoperatively. Fifteen other patients (13%) died from >60 days to up to 13 years postoperatively. The unadjusted survival analysis showed that late survival was significantly better in the unicuspid/bicuspid valve structure group than in the tricuspid valve structure group (log-rank test p = 0.001), but that it was not affected by gender (male vs female), preoperative severity of the AS (transvalvular peak pressure gradient >50 vs < or =50 mm Hg), or by performance of CABG. The aortic valve was congenitally unicuspid in 18 patients (15%), congenitally bicuspid in 84 (70%), and 3-cuspid in 18 (15%). In conclusion, aortic valve structure affected the unadjusted late survival in quinquagenarians undergoing AVR for AS, but concomitant CABG, gender, and transvalvular peak systolic gradient had no effect.