Extent of Coronary Artery Disease in Patients With Stenotic Bicuspid Versus Tricuspid Aortic Valves

Abstract

Background Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation, which is often complicated by aortic valve stenosis (AoS). In tricuspid aortic valve (TAV), AoS strongly associates with coronary artery disease (CAD) with common pathophysiological factors. Yet, it remains unclear whether AoS in patients with BAV is also associated with CAD. This study investigated the association between the aortic valve morphological features and the extent of CAD. Methods and Results A single-center study was performed, including all patients who underwent an aortic valve replacement attributable to AoS between 2006 and 2019. Coronary sclerosis was graded on preoperative coronary angiographies using the coronary artery greater even than scoring method, which divides the coronaries in 28 segments and scores nonobstructive (20%-49% sclerosis) and obstructive coronary sclerosis (>49% sclerosis) in each segment. Multivariate analyses were performed, controlling for age, sex, and CAD risk factors. A total of 1296 patients (931 TAV and 365 BAV) were included, resulting in 548 matched patients. Patients with TAV exhibited more CAD risk factors (odds ratio [OR], 2.66; 95% CI, 1.79-3.96; P<0.001). Patients with BAV had lower coronary artery greater even than 20 (1.61±2.35 versus 3.60±2.79) and coronary artery greater even than 50 (1.24±2.43 versus 3.37±3.49) scores (P<0.001), even after correcting for CAD risk factors (P<0.001). Patients with TAV more often needed concomitant coronary revascularization (OR, 3.50; 95% CI, 2.42-5.06; P<0.001). Conclusions Patients with BAV who are undergoing surgery for AoS carry a lower cardiovascular risk profile, correlating with less coronary sclerosis and a lower incidence of concomitant coronary revascularization compared with patients with TAV.

Keywords: aortic valve replacement; aortic valve stenosis; bicuspid aortic valve; coronary artery disease.

Figure 1. Coronary artery segments (according to coronary artery surgery study) and the corresponding weight factors used for the coronary artery greater even than score. ^,

Figure 2. Coronary artery disease (CAD) characteristics of the matched patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV).

Assessment of the number of CAD risk factors per patient showed higher amounts of CAD risk factors^** per patient in patients with TAV (top row bar diagrams) as compared to BAV patients. The medical histories of patients with TAV displayed higher rates of previous (prev) CAD events as compared to patients with BAV (odds ratio [OR], 4.15; 95% CI, 2.52–6.80; P<0.001) (second row bar diagrams). Concomitant coronary artery bypass grafting (CABG) was more often performed in patients with TAV (OR, 3.50; 95% CI, 2.42–5.06; P<0.001) (third row bar diagrams). Preoperative coronary angiographies showed higher rates of coronary sclerosis (both nonobstructive and obstructive) in patients with TAV, graded using the coronary artery greater even than (CAGE) scores (center bar graph). The bottom bar diagrams display the distribution of obstructive and nonobstructive CAD between patients with BAV and TAV, which shows higher rates of obstructive CAD in patients with TAV. *P<0.001; **Diabetes mellitus, hypertension, and/or hypercholesterolemia; †Previous myocardial infarction or instable angina pectoris.