Should the proximal arch be routinely replaced in patients with bicuspid aortic valve disease and ascending aortic aneurysm?

Ascending thoracic aortic aneurysm size at presentation and growth by diameter

AIM

To investigate the hypothesis that lung cancer screening allows for earlier identification of ascending thoracic aortic aneurysms (aTAAs) and that growth rates for aTAAs are greatest at larger sizes.

MATERIALS AND METHODS

This single referral centre retrospective study manually gathered computed tomography (CT) data from 732 patients presenting from July 2002 to August 2022. Five hundred and seventeen patients with aTAA >39 mm were identified to compare presenting diameter by year of presentation. Four hundred and thirty-two patients had CT examinations >3 months apart, allowing for growth analysis. Patients were separated by initial examination date (before or after 12/31/2013) for presenting size comparison. Patients were then divided into five groups based on aTAA diameter for growth rate analysis.

RESULTS

At identification, patients had a median aTAA diameter of 44 mm (IQR 41-47 mm). Patients with aTAAs identified prior to December 2013 (n=129) had an average aTAA diameter 1.7 mm larger than those identified later (n=388; p=0.003). The growth analysis showed an average growth rate of 0.1 mm/year (p<0.001) across the entire cohort. Patients with an aTAA diameter of ≥55 mm (n=12) grew the fastest at 1.9 mm/year (p<0.001). In the <40 mm group (n=43), the aTAAs expanded at 0.2 mm/year, faster than the 0.1 mm/year of the slowest expanding 45-49 mm group (n=130; p=0.04).

CONCLUSION

aTAA size at discovery was larger before lung cancer screening guidelines took effect in December 2013. The largest aTAAs expanded fastest, but growth rates were slowest in the medium-sized 45-49 mm diameter group.

The effect of adding an open distal anastomosis to proximal aneurysm repairs in bicuspid aortopathy

OBJECTIVES

To determine the role of adding open distal anastomosis to proximal aortic aneurysm repairs in bicuspid aortic valve (BAV) patients.

METHODS

Retrospective review was performed of 1132 patients at our Aortic Center between 2005 and 2019. Inclusion criteria were all patients diagnosed with a BAV who underwent proximal aortic aneurysm repair with open or clamped distal anastomosis. Exclusion criteria were patients without a BAV, age < 18 years, aortic arch diameter ≥ 4.5 cm, type A aortic dissection, previous ascending aortic replacement, ruptured aneurysm, and endocarditis. Propensity score matching in a 2:1 ratio (220 clamped: 121 open repairs) on 18 variables was performed.

RESULTS

Median follow-up time was 45.6 months (range 7.2-143.4 months). In the matched groups, no significant differences were observed between the respective open and clamped distal anastomosis groups for Kaplan Meier 10-year survival (86.9% vs. 92.9%; p = 0.05) and landmark survival analysis after 1 year (90.6%; vs. 93.3%; p = 0.39). Overall incidence of aortic arch-related reintervention was low (n = 3 total events). In-hospital complications were not significantly different in the open with respect to the clamped repair group, including in-hospital mortality (2.5% vs. 0.5%; p = 0.13) and stroke (0% vs. 0.9%; p = 0.54). In multivariable analysis, open distal anastomosis repair was not associated with long-term mortality (Hazard Ratio (HR) 1.98; p = 0.06).

CONCLUSION

We found no significant inter-group differences in survival, reintervention, or in-hospital complication rates, with low rates of mortality, and aortic arch-related reintervention, suggesting adding open distal anastomosis may not provide benefit in BAV patients undergoing proximal aortic aneurysm repairs.

Long-term outcome of hemiarch replacement in a proximal aortic aneurysm repair: analysis of over 1000 patients

OBJECTIVES

The aim of this study was to investigate the impact of hemiarch replacement in patients undergoing an open repair of proximal thoracic aortic aneurysm without arch aneurysm.

METHODS

A retrospective review was performed on 1132 patients undergoing proximal aortic aneurysm repair at our Aortic Center between 2005 and 2019. Inclusion criteria were all patients undergoing root or ascending aortic aneurysm repair with or without hemiarch replacement. Exclusion criteria were age <18 years, aortic arch diameter ≥4.5 cm, type A aortic dissection, previous ascending aortic replacement, ruptured aneurysm and endocarditis. Propensity score matching in a 2:1 ratio (573 non-hemiarch: 288 hemiarch) on 19 baseline characteristics was performed. The median follow-up time was 46.8 months (range 0.1-170.4 months).

RESULTS

Hemiarch patients had significantly lower 10-year survival in the matched cohort (hemiarch 73.8%; 66.9-81.4%; vs non-hemiarch 86.5%; 81.1-92.3%; P < 0.001), driven by higher in-hospital mortality rate (4% vs 1%; P < 0.001). Cumulative incidence of aortic arch reintervention rates at 10 years was similarly low (hemiarch 1.0%; 0-2.5% vs non-hemiarch 1.3%; 0-2.6%, P = 0.615). Multivariate analysis with hazard ratios of the overall cohort showed hemiarch as an independent factor associated with long-term mortality (2.16; 1.42-3.27; P < 0.001) but not with aortic arch reintervention (0.76; 0.14-4.07, P = 0.750).

CONCLUSIONS

Hemiarch repair may be associated with higher short-term mortality compared to non-hemiarch. Arch reintervention was rare after a repair of proximal thoracic aortic aneurysm without arch aneurysm. Our data call for larger and prospective studies to further delineate the utility of hemiarch repair in proximal aortic surgery.

Imaging surveillance after open aortic repair: a feasibility study of three-dimensional growth mapping

 

OBJECTIVES

Confident growth assessment during imaging follow-up is often limited by substantial variability of diameter measurements and the fact that growth does not always occur at standard measurement locations. There is a need for imaging-based techniques to more accurately assess growth. In this study, we investigated the feasibility of a three-dimensional aortic growth assessment technique to quantify aortic growth in patients following open aortic repair.

METHODS

Three-dimensional aortic growth was measured using vascular deformation mapping (VDM), a technique which quantifies the localized rate of volumetric growth at the aortic wall, expressed in units of Jacobian (J) per year. We included 16 patients and analysed 6 aortic segments per patient (96 total segments). Growth was assessed by 3 metrics: clinically reported diameters, Jacobian determinant and targeted diameter re-measurements.

RESULTS

VDM was able to clearly depict the presence or absence of localized aortic growth and allows for an assessment of the distribution of growth and its relation to anatomic landmarks (e.g. anastomoses, branch arteries). Targeted diameter change showed a stronger and significant correlation with J (r = 0.20, P = 0.047) compared to clinical diameter change (r = 0.15, P = 0.141). Among 20/96 (21%) segments with growth identified by VDM, growth was confirmed by clinical measurements in 7 and targeted re-measurements in 11. Agreement of growth assessments between VDM and diameter measurements was slightly higher for targeted re-measurements (kappa = 0.38) compared to clinical measurements (kappa = 0.25).

CONCLUSIONS

Aortic growth is often uncertain and underappreciated when assessed via standard diameter measurements. Three-dimensional growth assessment with VDM offers a more comprehensive assessment of growth, allows for targeted diameter measurements and could be an additional tool to determine which post-surgical patients at high and low risk for future complications.

Life Expectancy after Surgery for Ascending Aortic Aneurysm

Introduction: The life expectancy of patients who undergo ascending aortic replacement is unknown. The life expectancy of a population depends on a collection of environmental and socio-economic factors of the territory where they reside. Our aim was to compare the life expectancy of patients undergoing surgery for ascending aortic aneurysm with that of the general population matching by age, sex, and territory. In addition, we aimed to know the late complications, causes of death and risk factors. Methods: All patients who underwent elective replacement of an ascending aortic aneurysm at our institution between 2000 and 2019 were included. The long-term survival of the sample was compared with that of the general population using data of the National Institute of Statistics. Results: For patients who survived the postoperative period, observed cumulative survival at three, five and eight years was 94.07% (95% CI 91.87%-95.70%), 89.96% (95% CI 86.92%-92.33%) and 82.72% (95% CI 77.68%-86.71%). Cumulative survival of the general population at three, five and eight years was 93.22%, 88.30%, and 80.27%. Cancer and cardiac failure were the main causes of death. Conclusions: Long-term survival of patients undergoing elective surgery for ascending aortic aneurysm who survive the postoperative period completely recover their life expectancy.

The evolution of treatments for uncomplicated type B intramural hematoma patients

OBJECTIVES

We aimed to investigate whether uncomplicated type B intramural hematoma (IMHB) patients with known evolution predictors could benefit from more aggressive therapy.

METHODS

Retrospective analysis was performed in uncomplicated IMHB patients with evolution predictors between January 2001 and August 2018. Cox proportional hazard models were constructed to identify the specific factors associated with aorta-related mortality.

RESULTS

A total of 226 uncomplicated acute IMHB patients with evolution predictors were included. The conventional therapy group included 187 patients, and the other 39 patients received the more aggressive therapy. Aorta-related mortality in the first year was higher in the conventional therapy group than in the more aggressive therapy group (15% vs 2.5%, P = .035), and more patients died after thoracic endovascular aortic repair (TEVAR) (13 of 27 patients, 48.1% vs 2.5%, P < .001). The more aggressive therapy group had a higher rate of hematoma resolution than the conventional therapy group (81.6% vs 62.2%, P = .024), a lower possibility of hematoma worsening (2.6% vs 17.0%, P = .021), and a lower reintervention rate (0% vs 11.9%, P = .028). Cox regression analysis revealed that a higher rate of focal intimal disruption (FID) development (hazard ratio [HR], 3.99; 95% confidence interval [CI], 1.16-11.46, P = .010), and a higher C-reactive protein (CRP) level (HR, 1.27; 95% CI, 1.16-1.40, P < .001) were associated with increased aorta-related mortality.

CONCLUSIONS

More aggressive therapy for uncomplicated IMHB patients with evolution predictors during the acute phase may result in better clinical outcomes. A higher rate of FID development and a higher CRP level are associated with increased aorta-related mortality.

Open hemiarch versus clamped ascending aorta replacement for aortopathy during initial bicuspid aortic valve replacement

BACKGROUND

There is controversy regarding the extent of aortic resection necessary in patients with aortopathy related to bicuspid aortic valve disease. To address this issue, we reviewed our experience in patients undergoing ascending aorta replacement during bicuspid aortic valve replacement.

METHODS

We reviewed 702 patients who underwent ascending aorta replacement at the time of initial nonemergent native bicuspid aortic valve replacement at our institution between January 2000 and June 2017. Treatment cohorts included an open hemiarch replacement group (n = 225; 32%) and a clamped ascending aorta replacement group (n = 477; 68%).

RESULTS

Median patient age was 60 years (interquartile range [IQR], 51-67 years), female sex was present in 113 patients 16%, ejection fraction was 62% (IQR, 56%-66%), and aortic arch diameter was 33 mm (IQR, 29-36 mm). Cardiopulmonary bypass time was longer in the hemiarch replacement group (188 minutes vs 97 minutes; P < .001). Procedure-related complications (36%) and mortality (<1%) were similar in the 2 groups; however, the hemiarch group had an increased odds of blood transfusion (odds ratio, 1.62; 95% confidence interval [CI], 1.15-2.28; P = .006). The median duration of follow-up was 6.0 years (95% CI, 5.3-6.8 years). Overall survival was 94 ± 1% at 5 years and 80 ± 2% at 10 years. Multivariable analysis demonstrated similar survival in the 2 groups (hazard ratio, 0.83; 95% CI, 0.51-1.33; P = .439). No repeat aortic arch operations were done for aortopathy over the duration of clinical follow-up.

CONCLUSIONS

Compared with patients in the clamped ascending aorta replacement group, patients in the hemi-arch replacement group had longer cardiopulmonary bypass and aortic cross-clamp times, along with an increased risk of blood transfusion, but similar freedom from repeat aortic arch operation and survival. We identified no advantage of performing hemiarch replacement in the absence of aortic arch dilation.

The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: Full online-only version

Bicuspid aortic valve disease is the most common congenital cardiac disorder, being present in 1% to 2% of the general population. Associated aortopathy is a common finding in patients with bicuspid aortic valve disease, with thoracic aortic dilation noted in approximately 40% of patients in referral centers. Several previous consensus statements and guidelines have addressed the management of bicuspid aortic valve-associated aortopathy, but none focused entirely on this disease process. The current guidelines cover all major aspects of bicuspid aortic valve aortopathy, including natural history, phenotypic expression, histology and molecular pathomechanisms, imaging, indications for surgery, surveillance, and follow-up, and recommendations for future research. It is intended to provide clinicians with a current and comprehensive review of bicuspid aortic valve aortopathy and to guide the daily management of these complex patients.

The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: Executive summary

Bicuspid aortic valve disease is a common congenital cardiac disorder, being present in 1% to 2% of the general population. Associated aortopathy is a common finding in patients with bicuspid aortic valve disease, with thoracic aortic dilation noted in approximately 40% of patients in referral centers. Several previous consensus statements and guidelines have addressed the management of bicuspid aortic valve-associated aortopathy, but none focused entirely on this disease process. The current document is an executive summary of "The American Association for Thoracic Surgery Guidelines on Bicuspid Aortic Valve-Related Aortopathy." All major aspects of bicuspid aortic valve aortopathy, including natural history, phenotypic expression, histology and molecular pathomechanisms, imaging, indications for surgery, surveillance, and follow-up, and recommendations for future research are contained within these guidelines. The current executive summary serves as a condensed version of the guidelines to provide clinicians with a current and comprehensive review of bicuspid aortic valve aortopathy and to guide the daily management of these complex patients.

Evolving Surgical Approaches to Bicuspid Aortic Valve Associated Aortopathy

Bicuspid aortic valve (BAV) is the most common congenital cardiac pathology which results from the fusion of two adjacent aortic valve cusps. It is associated with dilatation of the aorta, known as bicuspid valve-associated aortopathy or bicuspid aortopathy. Bicuspid aortopathy is progressive and is linked with adverse clinical events. Hence, frequent monitoring and early intervention with prophylactic surgical resection of the proximal aorta is often recommended. Over the past two decades resection strategies and surgical interventions have mainly been directed by surgeon and institution preferences. These practices have ranged from conservative to aggressive approaches based on aortic size and growth criteria. This strategy, however, may not best reflect the risks of important aortic events. A new set of guidelines was proposed for the treatment of bicuspid aortopathy. Herein, we will highlight the most recent findings pertinent to bicuspid aortopathy and its management in the context of a case presentation.

The aortic root does not dilate over time after replacement of the aortic valve and ascending aorta in patients with bicuspid or tricuspid aortic valves

OBJECTIVE

Whether the aortopathy associated with bicuspid aortic valve (BAV) disease occurs secondary to genetic or hemodynamic factors remains controversial. In this article we describe the natural history of the aortic root in patients with bicuspid versus tricuspid aortic valves (TAVs) after replacement of the aortic valve and ascending aorta.

METHODS

From 1990 to 2010, 406 patients (269 BAV, 137 TAV) underwent aortic valve and ascending aorta replacement at a single institution. Patients with aortic dissection, endocarditis, previous aortic surgery, or Marfan syndrome were excluded. All available follow-up imaging was reviewed.

RESULTS

Mean imaging follow-up was 5.5 (±5.3) years. Of all patients, 66.5% had at least 1 aortic root measurement after the index operation. Baseline aortic diameter was comparable between groups. In patients with BAV, aortic root diameter increased at a clinically negligible rate over time (0.654 mm per year; 95% confidence interval, 0.291-1.016; P < .001), similar to patients with TAV (P = .92). Mean clinical follow-up was 8.1 (±5.4) years. During follow-up, 18 patients underwent reoperation, 89% for a degenerated bioprosthetic aortic valve. Only 1 patient underwent reoperation for a primary indication of aortic aneurysmal disease, 22 years after the index operation. There were no differences in cumulative incidence rates of aortic reoperation (P = .14) between patients with BAV and TAV.

CONCLUSIONS

Mid-term imaging after aortic valve and ascending aorta replacement indicates that if the aortic root is not dilated at the time of surgery, the risk of enlargement over time is minimal, negating the need for prophylactic root replacement in patients with BAV or TAV.

Elective primary aortic root replacement with and without hemiarch repair in patients with no previous cardiac surgery

OBJECTIVE

Excellent outcomes have been established for elective aortic root replacement (ARR). It is less clear whether extending the repair into the proximal aortic arch with hypothermic circulatory arrest increases risk. We examined the early outcomes of elective, primary ARR, with and without hemiarch replacement, in patients without previous cardiac surgery.

METHODS

Over a 4-year period, 140 non-redo patients (median age, 54 years) underwent elective, primary ARR for root aneurysms; 119 patients (85%) had hemiarch replacement, and 21 (15%) had only ascending aortic replacement. Valve-sparing ARR was performed in 41 cases (29.3%) and valve-replacing ARR in 99 (70.7%). Moderate hypothermic circulatory arrest and antegrade cerebral perfusion were used in 118 (99%) hemiarch repairs.

RESULTS

There were no operative deaths or permanent strokes. Complications included temporary renal dialysis (n = 1; 4.8%), transient neurologic deficit (n = 2; 9.5%), and tracheostomy (n = 2; 9.5%) after ascending aortic repair and bleeding requiring reoperation (n = 4; 3.4%), pericardial effusion requiring drainage (n = 9; 7.6%), and tracheostomy (n = 2; 1.7%) after hemiarch replacement. No stroke was observed in the hemiarch group (P = .022; univariate analysis). The extent of the repair into the proximal arch did not appear to be associated with any adverse effect.

CONCLUSIONS

In non-redo patients, elective primary ARR has excellent early outcomes, regardless of whether repair extends into the proximal arch. Additional elective hemiarch replacement with moderate hypothermic circulatory arrest and antegrade cerebral perfusion has a low risk of neurologic complications and should be performed if necessary. Long-term data are needed to compare the rates of reintervention in the aortic arch in patients with or without proximal arch replacement.

Bicuspid aortic valve aortopathy in adults: Incidence, etiology, and clinical significance

Bicuspid aortic valve is the most common congenital heart defect and is associated with an aortopathy manifested by dilatation of the ascending thoracic aorta. The clinical consequences of this aortopathy are the need for periodic monitoring of aortic diameters, elective prophylactic surgical aortic repair, and the occurrence of aortic dissection or rupture. This review describes the current knowledge of BAV aortopathy in adults, including incidence, pathophysiologic insights into its etiology, contemporary hypothesis-generating observations into its complications, and recommendations for monitoring and intervention.

Current topics on bicuspid aortic valve: clinical aspects and surgical management

Bicuspid aortic valve (BAV) has been identified as the most common heart valve anomaly and is considered to be a heritable disorder that affects various cardiovascular disorders, including aortopathy. Current topics regarding the clinical management of BAV including surgical strategies with or without concomitant aortic repair or replacement are attracting interest, in addition to the pathological and morphological aspects of BAV as well as aortopathy. However, surgical indications are still being debated and are dependent on current clinical guidelines and surgeons' preferences. Although clinical guidelines have already been established for the management of BAV with or without aortopathy, many studies on clinical management and surgical techniques involving various kinds of subjects have previously been published. Although a large number of studies concerning the clinical aspects of BAV have been reviewed in detail, controversy still surrounds the clinical and surgical management of BAV. Therefore, surgeons should carefully consider valve pathology when deciding whether to replace the ascending aorta. In this review, we summarized current topics on BAV and the surgical management of diseased BAV with or without aortopathy based on previous findings, including catheter-based interventional management.

Knowledge, attitudes, and practice patterns in surgical management of bicuspid aortopathy: a survey of 100 cardiac surgeons

OBJECTIVE

Clinical practice guidelines have been established for surgical management of the aorta in bicuspid aortic valve disease. We hypothesized that surgeons' knowledge of and attitudes toward bicuspid aortic valve aortopathy influence their surgical approaches.

METHODS

We surveyed cardiac surgeons to probe the knowledge of, attitudes toward, and surgical management of bicuspid aortopathy. A total of 100 Canadian adult cardiac surgeons participated.

RESULTS

Fifty-two percent of surgeons believed that the mechanism underlying aortic dilation in those with bicuspid aortic valve was due to an inherent genetic abnormality of the aorta, whereas only 2% believed that altered valve-related processes were involved in this process. Only a minority (15%) believed that bicuspid valve leaflet fusion type is associated with a unique pattern of aortic dilatation aortic phenotype. Sixty-five percent of surgeons recommended echocardiographic screening of first-degree relatives of patients with bicuspid aortic valve. Most surgeons (61%) elected to replace the aorta when the diameter is 45 mm or greater at the time of valve surgery. Fifty-five percent of surgeons surveyed suggested that in the absence of concomitant valvular disease, they would recommend ascending aortic replacement at a threshold of 50 mm or greater. Approximately one third of surgeons suggested that they would elect to replace a mildly dilated ascending aorta (40 mm) at the time of valve surgery. The most common surgical approach (61%) for combined valve and aortic surgery was aortic valve replacement and supracoronary replacement of the ascending aorta, and only a minority suggested the use of deep hypothermic circulatory arrest and open distal anastomosis. More aggressive approaches were favored with greater surgeon experience, and when circulatory arrest was chosen, the majority (68%) suggested they would use antegrade cerebral perfusion. In the setting of aortic insufficiency and a dilated aorta, 42% of surgeons suggested that they would perform valve-sparing surgery. Of note, 40% of respondents used an index measure of aortic size to body surface area in addition to absolute aortic diameter in assessing the threshold for intervention.

CONCLUSIONS

This large survey uncovered significant gaps in the knowledge and attitudes of surgeons toward the diagnosis and management of bicuspid aortopathy, many of which were at odds with current guideline recommendations. Efforts to promote knowledge translation in this area are strongly encouraged.

Long-term results after proximal thoracic aortic redo surgery

OBJECTIVE

To evaluate early and mid-term results in patients undergoing proximal thoracic aortic redo surgery.

METHODS

We analyzed 60 patients (median age 60 years, median logistic EuroSCORE 40) who underwent proximal thoracic aortic redo surgery between January 2005 and April 2012. Outcome and risk factors were analyzed.

RESULTS

In hospital mortality was 13%, perioperative neurologic injury was 7%. Fifty percent of patients underwent redo surgery in an urgent or emergency setting. In 65%, partial or total arch replacement with or without conventional or frozen elephant trunk extension was performed. The preoperative logistic EuroSCORE I confirmed to be a reliable predictor of adverse outcome- (ROC 0.786, 95%CI 0.64-0.93) as did the new EuroSCORE II model: ROC 0.882 95%CI 0.78-0.98. Extensive individual logistic EuroSCORE I levels more than 67 showed an OR of 7.01, 95%CI 1.43-34.27. A EuroSCORE II larger than 28 showed an OR of 4.44 (95%CI 1.4-14.06). Multivariate logistic regression analysis identified a critical preoperative state (OR 7.96, 95%CI 1.51-38.79) but not advanced age (OR 2.46, 95%CI 0.48-12.66) as the strongest independent predictor of in-hospital mortality. Median follow-up was 23 months (1-52 months). One year and five year actuarial survival rates were 83% and 69% respectively. Freedom from reoperation during follow-up was 100%.

CONCLUSIONS

Despite a substantial early attrition rate in patients presenting with a critical preoperative state, proximal thoracic aortic redo surgery provides excellent early and mid-term results. Higher EuroSCORE I and II levels and a critical preoperative state but not advanced age are independent predictors of in-hospital mortality. As a consequence, age alone should no longer be regarded as a contraindication for surgical treatment in this particular group of patients.

David valve-sparing aortic root replacement: equivalent mid-term outcome for different valve types with or without connective tissue disorder

OBJECTIVE

Although implicitly accepted by many that the durability of valve-sparing aortic root replacement in patients with bicuspid aortic valve disease and connective tissue disorders will be inferior, this hypothesis has not been rigorously investigated.

METHODS

From 1993 to 2009, 233 patients (27% bicuspid aortic valve, 40% Marfan syndrome) underwent Tirone David valve-sparing aortic root replacement. Follow-up averaged 4.7 ± 3.3 years (1102 patient-years). Freedom from adverse outcomes was determined using log-rank calculations.

RESULTS

Survival at 5 and 10 years was 98.7% ± 0.7% and 93.5% ± 5.1%, respectively. Freedom from reoperation (all causes) on the aortic root was 92.2% ± 3.6% at 10 years; 3 reoperations were aortic valve replacement owing to structural valve deterioration. Freedom from structural valve deterioration at 10 years was 96.1% ± 2.1%. No significant differences were found in survival (P = .805, P = .793, respectively), reoperation (P = .179, P = .973, respectively), structural valve deterioration (P = .639, P = .982, respectively), or any other functional or clinical endpoints when patients were stratified by valve type (tricuspid aortic valve vs bicuspid aortic valve) or associated connective tissue disorder. At the latest echocardiographic follow-up (95% complete), 202 patients (94.8%) had none or trace aortic regurgitation, 10 (4.7%) mild, 0 had moderate to severe, and 1 (0.5%) had severe aortic regurgitation. Freedom from greater than 2+ aortic regurgitation at 10 years was 95.3% ± 2.5%. Six patients sustained acute type B aortic dissection (freedom at 10 years, 90.4% ± 5.0%).

CONCLUSIONS

Tirone David reimplantation valve-sparing aortic root replacement in carefully selected young patients was associated with excellent clinical and echocardiographic outcome in patients with either a tricuspid aortic valve or bicuspid aortic valve. No demonstrable adverse influence was found for Marfan syndrome or connective tissue disorder on durability, clinical outcome, or echocardiographic results.

Current indications for surgical repair in patients with bicuspid aortic valve and ascending aortic ectasia

Preventive surgical repair of the moderately dilated ascending aorta/aortic root in patients with bicuspid aortic valve (BAV) is controversial. Most international reference centers are currently proposing a proactive approach for BAV patients with a maximum ascending aortic/root diameter of 45 mm since the risk of dissection/rupture raises significantly with an aneurysm diameter >50 mm. Current guidelines of the European Society of Cardiology (ESC) and the joint guidelines of the American College of Cardiology (ACC)/American Heart Association (AHA) recommend elective repair in symptomatic patients with dysfunctional BAV (aortic diameter ≥45 mm). In asymptomatic patients with a well-functioning BAV, elective repair is recommended for diameters ≥50 mm, or if the aneurysm is rapidly progressing (rate of 5 mm/year), or in case of a strong family history of dissection/rupture/sudden death, or with planned pregnancy. As diameter is likely not the most reliable predictor of rupture and dissection and the majority of BAV patients may never experience an aortic catastrophe at small diameters, an overly aggressive approach almost certainly will put some patients with BAV unnecessarily at risk of operative and early mortality. This paper discusses the indications for preventive, elective repair of the aortic root, and ascending aorta in patients with a BAV and a moderately dilated—or ectatic—ascending aorta.

Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair

OBJECTIVE

Retrograde ascending aortic dissection (rAAD) is a potential complication of thoracic endovascular aortic repair (TEVAR), yet little data exist regarding its occurrence. This study examines the incidence, etiology, and outcome of this event.

METHODS

A prospective institutional database was used to identify cases of acute rAAD following TEVAR from a cohort of 309 consecutive procedures from March 2005 (date of initial Food and Drug Administration approval) to September 2010. The database was analyzed for the complication of rAAD as well as relevant patient and operative variables.

RESULTS

The incidence of rAAD was 1.9% (6/309); all cases occurred with proximal landing zone in the ascending aorta and/or arch (zones 0-2). All were identified in the perioperative period (range, 0-6 days) with 33% (2/6) 30-day/in-hospital mortality. Eighty-three percent (5/6) underwent emergent repair; one patient died without repair. rAAD patients were similar to the non-rAAD group (n = 303) across pertinent variables, including age, gender, race, and device size (all P > .1). rAAD incidence by aortic pathology was 1.0% (2/200) for aneurysm, 4.4% (4/91) for dissection, and 0% (0/18) for transection; P = .08. rAAD incidence by device was TAG (Gore) 1.0% (2/205), Talent (Medtronic) 4.7% (2/43), and Zenith TX2 (Cook) 3.6% (2/55). rAAD incidence was observed to be higher among patients with an ascending aortic diameter ≥ 4.0 cm (4.8% vs 0.9% for ascending diameter <4.0 cm); P = .047. Incidence was also higher with proximal landing zone in the native ascending aorta (zone 0) 6.9% (2/29) versus 1.4% for all others (4/280); P = .101. For patients with dissection pathology and an ascending aortic diameter ≥ 4.0 cm, 11% (3/28) suffered rAAD; with the combination of native ascending aorta (zone 0) landing zone measuring ≥ 4.0 cm, the incidence was 25% (2/8). Definitive diagnosis was by computed tomography angiography (n = 1), intraoperative transesophageal echocardiography (n = 3), intraoperative arteriography (n = 1), or postmortem autopsy (n = 1).

CONCLUSIONS

rAAD is a lethal early complication of TEVAR, which may be more common when treating dissection, with devices utilizing proximal bare springs or barbs for fixation, with native zone 0 proximal landing zone and with ascending aortic diameter ≥ 4 cm. Combinations of these risk factors may be particularly high risk. Intraoperative imaging assessment of the ascending aorta should be conducted following TEVAR to avoid under-recognition. National database reporting of this complication is needed to ensure safety and proper application of emerging TEVAR technology.