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Urbanski PP, Atieh A, Lehmkuhl L, Irimie V, Zhan X, Thamm T, Ahmidou A, Nasra W, Diegeler A. Selective sinus replacement for aortic root repair in bicuspid aortopathy. J Thorac Cardiovasc Surg 2024; 167:908-917.e6. [PMID: 35461710 DOI: 10.1016/j.jtcvs.2022.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/09/2022] [Accepted: 03/16/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate the results after selective sinus replacement (SSR) for aortic root remodeling in bicuspid aortopathy. METHODS Among 662 patients who underwent root repair using SSR between 2005 and 2020, there were 114 with bicuspid aortopathy. SSR was performed either as an isolated procedure (31) or as an adjunct to aortic valve repair (83) and was adjusted to the existing aortic annulus diameter rather than a downsized diameter. In valves with asymmetrical commissural orientation, the repair aimed for the achievement of a 180°-commissural orientation. RESULTS Abolishment of aortic insufficiency (AI) ≥2+ using root repair alone was only possible in 2 patients with acute-dissection-related AI, yet isolated root repair was also performed in 29 further patients with no/mild AI. All remaining patients with AI ≥2+ presented cusp-related regurgitation and necessitated an additional valve repair. During the mean follow-up of 91 months (range, 13-196), a relevant valve defect (AI ≥3+ in 8, stenosis in 2) occurred in 10 patients (all after combined repair) resulting in an estimated freedom from a relevant aortic valve defect and/or reoperation of 96 ± 2%, 89 ± 4%, and 82 ± 6% at 5, 10, and 12 years, respectively. Echocardiographically, no patient revealed a considerable change of form or size of the repaired root nor was any root reintervention necessary. CONCLUSIONS Patient-tailored root repair using SSR is a very effective and durable valve-sparing approach for bicuspid aortopathy. Aortic cusp repair is decisive for both abolishment of AI in bicuspid aortopathy and for the functional durability of the repaired aortic valve.
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Affiliation(s)
- Paul P Urbanski
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany.
| | - Alaa Atieh
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Lukas Lehmkuhl
- Department of Radiology, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Vadim Irimie
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Xiaochun Zhan
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Tarvo Thamm
- Department for Medical Statistics, Campus Bad Neustadt, Bad Neustadt, Germany
| | - Akram Ahmidou
- Department for Medical Statistics, Campus Bad Neustadt, Bad Neustadt, Germany
| | - Wasim Nasra
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Anno Diegeler
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
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Sievers HH. The bicuspid aortic valve complex: still a mystery. Eur J Cardiothorac Surg 2021; 60:479-480. [PMID: 34292340 DOI: 10.1093/ejcts/ezab073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 01/25/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Hans-Hinrich Sievers
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
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3
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Suzuki Y, Levy G, DeAnda A. Is prophylactic root replacement needed to prevent future root aneurysm in bicuspid aortic valve patients? JTCVS OPEN 2021; 6:101-105. [PMID: 36003549 PMCID: PMC9390202 DOI: 10.1016/j.xjon.2020.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Yota Suzuki
- Address for reprints: Abe DeAnda, Jr, MD, Division of Cardiovascular and Thoracic Surgery, UTMB-Galveston, 301 University Blvd, Galveston, TX, 77551.
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Siurana JM, Sabaté-Rotés A, Ayerza A, Jimenez L, Figueras-Coll M, Gonzalez MA. Adolescents with bicuspid aortic valve: Which criteria should we use for aortic dilatation? Int J Cardiol 2021; 333:90-93. [PMID: 33757790 DOI: 10.1016/j.ijcard.2021.03.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Criteria to define aortic dilatation in bicuspid aortic valve (BAV) patients are different for children and adults. The objective of this study was to find the best reference tool to define dilation of the aortic root (AR) and the ascending aorta (AA) in BAV adolescents with an adult body surface area (BSA). METHODS Patients recruited were ≥10-years-old with a BSA ≥1.5 m2. Three measurements of the AR and AA were compared: z-score, the BSA-indexed value (BSA-IV) and the absolute value (AV), with thresholds in +2/+3, 21 mm/m2 and 40 mm, respectively. RESULTS 231 subjects were collected from the Pediatric REVAB database, with a median age and BSA of 14-year-old and 1.67 m2. Significant differences were reported in the AA: 109 (47%) patients had a z-score ≥2 and 67 (29%) a Z ≥ 3, but only 9 (3%) a BSA-IV ≥21 mm/m2 (p < 0.01 and p < 0.01) and 2 (0.9%) an AV ≥40 mm (p = 0.22 and p = 0.08). CONCLUSION Our results indicate that in the AA there are a significant number of patients in which it would be recommendable changing to BSA-IV when children are older than 10-year-old and BSA ≥1.5 m2. Regarding the AR, criteria for dilatation seems not to be influenced by the reference chosen.
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Affiliation(s)
- Jose M Siurana
- Hospital HM Nens. HM Hospitales, Spain; Universitat Autònoma de Barcelona, Spain
| | - Anna Sabaté-Rotés
- Universitat Autònoma de Barcelona, Spain; Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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Etz CD, Haunschild J, Girdauskas E, Della Corte A, Fedak PWM, Schäfers HJ, Sundt TM, Borger MA. Surgical management of the aorta in BAV patients. Prog Cardiovasc Dis 2020; 63:475-481. [PMID: 32640281 DOI: 10.1016/j.pcad.2020.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 12/12/2022]
Abstract
Patients with a bicuspid aortic valve (BAV) frequently develop aneurysms of the aortic root and tubular ascending aorta. Aneurysms of the aortic arch, in the absence of concomitant aortopathies, are much less common. According to the 2018 American Association of Thoracic Surgery consensus guidelines on BAV-related aortopathy, prophylactic surgical aortic repair / replacement is recommended starting at a maximum aortic diameter of 50 mm in patients with risk factors. Concomitant aortic surgery is also recommended at an aortic diameter of 45 mm in those patients with other indications for cardiac surgery (most commonly aortic valve procedures). The ultimate goal of prophylactic aortic surgery is the prevention of aortic catastrophes, e.g. aortic rupture or acute aortic dissection, which are associated with high morbidity and mortality. The surgical technique used - in elective and emergency cases - depends on the involvement and nature of the aortic valve disease, as well as the extent of aortic aneurysm formation. The current review focusses on the surgical management of the aortic root, tubular ascending aorta, and proximal aortic arch in BAV patients. Despite the abovementioned recommendations, many BAV patients develop acute aortic syndromes below the recommended aortic diameter thresholds. Further research is therefore required in order to identify high-risk BAV subgroups that would benefit from earlier surgical repair.
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Affiliation(s)
- Christian D Etz
- University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Paul W M Fedak
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Canada
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Michael A Borger
- University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
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Nissen AP, Truong VTT, Alhafez BA, Puthumana JJ, Estrera AL, Body SC, Prakash SK. Surgical repair of bicuspid aortopathy at small diameters: Clinical and institutional factors. J Thorac Cardiovasc Surg 2020; 159:2216-2226.e2. [PMID: 31543305 PMCID: PMC7035185 DOI: 10.1016/j.jtcvs.2019.06.103] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/03/2019] [Accepted: 06/09/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Bicuspid aortic valve is a common risk factor for thoracic aortic aneurysm and dissection. Guidelines for elective ascending aortic intervention (AAI) in bicuspid aortic valve are derived from limited evidence, and the extent of practice variation due to patient and provider characteristics is unknown. Using data from 2 large cardiovascular registries, we investigated factors that influence decisions for AAI. METHODS All bicuspid aortic valve cases with known aortic diameters and surgical status were included. We used multivariable logistic regression to profile predictors of isolated aortic valve replacement (AVR) or AVR+AAI, stratified by patient characteristics, surgical indications, and institution. RESULTS We studied 2861 subjects at 18 institutions from 1996 to 2015. The median aortic diameter of patients who underwent AVR+AAI varied widely across institutions (39-52 mm). Aortic diameters were <45 mm in 38% of patients undergoing AVR+AAI. Patients who underwent AAI at <45 mm, compared with those managed nonoperatively, were younger (54 ± 13 vs 61 ± 15 years; P < .001) with more frequent aortic stenosis (53% vs 28%; P < .001) and regurgitation (52% vs 18%; P < .001). CONCLUSIONS Clinical and institutional factors influence the timing of AAI and are associated with significant variability in ascending aortic diameter at AAI across institutions. More than one third of patients with a bicuspid aortic valve undergo AAI at aortic diameters <45 mm. Long-term outcomes of this subgroup of patients, who may manifest earlier and more severe disease, are needed to determine the risk-benefit ratio of routine aortic interventions at smaller diameters.
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Affiliation(s)
- Alexander P Nissen
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, Houston, Tex; Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, Tex
| | - Van Thi Thanh Truong
- Center for Clinical Research & Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, Tex
| | - Bader A Alhafez
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jyothy J Puthumana
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston, Houston, Tex
| | - Simon C Body
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Siddharth K Prakash
- Division of Medical Genetics, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, Tex.
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Oner T, Akgun G, Ergin SO, Karadag H, Yucel İK, Celebi A. Risk Factors Associated with Ascending Aortic Aneurysms and Aortic Elasticity Parameters in Children with a Bicuspid Aortic Valve. Pediatr Cardiol 2019; 40:980-986. [PMID: 31016325 DOI: 10.1007/s00246-019-02102-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 04/05/2019] [Indexed: 11/28/2022]
Abstract
Aneurysms of the ascending aorta are frequently found in patients with a bicuspid aortic valve (BAV). This study assessed the risk factors of ascending aortic aneurysms and aortic elasticity in children with BAV. The study included 66 patients with no history of transcatheter intervention or surgical procedure who had been diagnosed with isolated BAV. Echocardiographic, blood pressure, and pulse measurements were obtained for all patients. The BAVs were classified as described by Sievers et al. (J Thorac Cardiovasc Surg 133:1226-1233, 2007), and aortic elasticity parameters were calculated using various formulas. The patients were divided into groups with and without cusp fusion, aortic stenosis (AS), aortic regurgitation (AR), or mixed lesions; the groups were then compared. The mean patient age was 10.43 ± 3.91 years; 15%he patients had no AS or AR, 33% had both AS and AR, 17% had AS alone, and 35% had AR alone. The most common type of BAV was type 5, and the ascending aorta z-scores were higher in children with mixed lesions and without a cusp fusion. Aortic distensibility (AD) was significantly higher, and the stiffness index was significantly lower, in patients with an ascending aorta z-score > 4. The ascending aortic z-scores were higher in the no-fusion and mixed lesion (AS + AR) groups, especially those originating from post-stenotic dilation due to AS. The AD was increased in patients with an ascending aorta z-score > 4. Patients should thus be monitored closely for dissection risk, and preventive medical treatment should be started early in those with AS without cusp fusion.
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Affiliation(s)
- Taliha Oner
- Department of Pediatric Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Uskudar, Istanbul, Turkey.
| | - Gokmen Akgun
- Department of Pediatric Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Uskudar, Istanbul, Turkey
| | - Selma Oktay Ergin
- Department of Pediatric Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Uskudar, Istanbul, Turkey
| | - Huseyin Karadag
- Department of Pediatric Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Uskudar, Istanbul, Turkey
| | - İlker Kemal Yucel
- Department of Pediatric Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Uskudar, Istanbul, Turkey
| | - Ahmet Celebi
- Department of Pediatric Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Uskudar, Istanbul, Turkey
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8
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Aortic replacement for bicuspid aortic valve aortopathy: When and why? J Thorac Cardiovasc Surg 2019; 157:520-525. [DOI: 10.1016/j.jtcvs.2018.06.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/22/2018] [Accepted: 06/04/2018] [Indexed: 01/15/2023]
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9
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Liu S, Tong M, Pan G, Li D, Xu J. Reply. Ann Thorac Surg 2018; 107:685. [PMID: 30395860 DOI: 10.1016/j.athoracsur.2018.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 09/20/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Shen Liu
- Department of Cardiovascular Surgery, Peking University International Hospital, 1 Life Park Rd, Life Science Park of Zhongguancun, Changping District, Beijing 102206, P.R. China
| | - Minghui Tong
- Department of Cardiovascular Surgery, Peking University International Hospital, 1 Life Park Rd, Life Science Park of Zhongguancun, Changping District, Beijing 102206, P.R. China
| | - Guangyu Pan
- Department of Cardiovascular Surgery, Peking University International Hospital, 1 Life Park Rd, Life Science Park of Zhongguancun, Changping District, Beijing 102206, P.R. China
| | - Dianyuan Li
- Department of Cardiovascular Surgery, Peking University International Hospital, 1 Life Park Rd, Life Science Park of Zhongguancun, Changping District, Beijing 102206, P.R. China
| | - Jianping Xu
- Department of Cardiovascular Surgery, Peking University International Hospital, 1 Life Park Rd, Life Science Park of Zhongguancun, Changping District, Beijing 102206, P.R. China.
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Sievers HH. Everybody is different: A plea for individualizing treatment of aortopathy. J Thorac Cardiovasc Surg 2018; 156:481-482. [DOI: 10.1016/j.jtcvs.2017.11.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 11/09/2017] [Indexed: 11/16/2022]
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Prakash SK, Estrera AL. Not "Z" end of the story: Do Z scores help to guide surgical decisions about the ascending aorta in patients with bicuspid aortic valve? J Thorac Cardiovasc Surg 2017; 155:560-561. [PMID: 29108714 DOI: 10.1016/j.jtcvs.2017.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Siddharth K Prakash
- Department of Internal Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex.
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Conti VR, DeAnda A. Ascending aortopathy with bicuspid aortic valve: Individualizing the threshold. J Thorac Cardiovasc Surg 2017; 155:535-536. [PMID: 29033042 DOI: 10.1016/j.jtcvs.2017.09.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 09/17/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Vincent R Conti
- Division of Cardiothoracic Surgery, University of Texas Medical Branch-Galveston, Galveston, Tex
| | - Abe DeAnda
- Division of Cardiothoracic Surgery, University of Texas Medical Branch-Galveston, Galveston, Tex.
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