Aortic root replacement in bicuspid versus tricuspid aortic valve patients

Abstract

Background: Concomitant replacement of the aortic root and aortic valve is a widely used treatment strategy in elective patients with aortic valve stenosis and root aneurysm. It is also a strategy frequently employed in patients with acute aortic dissection type A (AADA), involving the aortic root. Although more patients have undergone valve sparing procedures over the past decades, the classic 'modified Bentall technique' remains a valid option, particularly for patients with a bicuspid aortic valve (BAV). We aimed to compare the results of elective and emergency modified Bentall procedures in patients with bicuspid and tricuspid aortic valves (TAVs).

Methods: We retrospectively reviewed our database for patients undergoing either elective or emergency modified Bentall procedures between 2000 and 2018 and identified 827 elective cases (44% BAV) and 258 emergency cases (15% BAV). Analysis of intra- and postoperative outcomes and early mortality was performed. Due to inequality of the groups, a matching analysis was performed.

Results: We found BAV patients to be significantly younger (elective: 58±18 vs. 65±14, P<0.001; emergency: 49±17 vs. 62±19, P<0.001) and healthier at time of surgery. In the AADA cohort, malperfusion rate was not different between bicuspid and tricuspid patients, however bicuspid AADA patients presented more often with an entry in the aortic root. After matching, procedure times and early outcomes did not differ between the groups, except for significantly higher rates of respiratory failure in elective TAV patients (10% vs. 5%, P=0.033). The 30-day mortality was 2% in elective cases and 22% in emergency AADA surgery. A subgroup analysis of elective patients with aortic diameter <55 mm also showed excellent outcomes.

Conclusions: After adjustment for preoperative inequalities, no differences in early mortality and outcomes were found between bicuspid and tricuspid patients receiving elective or emergency modified Bentall surgery.

Keywords: Aortic root aneurysm; acute aortic dissection; aortic valve replacement; bicuspid aortic valve (BAV).

Figure 1

Covariates before and after propensity score matching (elective cases). GFR, glomerular filtration rate; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association classification of heart failure; ASA, American Society of Anesthesiologists physical status classification; CABG, coronary artery bypass grafting.

Figure 2

Covariates before and after genetic matching (cases with AADA). NYHA, New York Heart Association classification of heart failure; LVEF, left ventricular ejection fraction; CABG, coronary artery bypass grafting; AADA, acute aortic dissection type A.