Stentless valves for bicuspid and tricuspid aortic valve disease

Abstract

Objective: To determine long-term survival and reoperation rate in patients with a bicuspid aortic valve (BAV) and patients with a tricuspid aortic valve (TAV) after stentless aortic valve replacement (AVR)/aortic root replacement (ARR).

Methods: Between 1992 and 2014, 1293 patients underwent first AVR/ARR with a stentless aortic valve using the modified inclusion operating technique, including 741 patients with a TAV and 552 with a BAV. Using propensity scoring with 26 variables, 330 matched pairs were identified with AVR with or without ascending aorta/arch replacement. Data were obtained through chart review, surveys, and the National Death Index.

Results: Patient demographics were similar in the propensity score-matched groups. Both groups had similar cardiopulmonary bypass, cross-clamp, and hypothermia circulatory arrest times, cerebral protection strategies, and rate of aortic arch replacement. The median size of implanted valves was similar (BAV: 27 mm [range, 25-29 mm] vs TAV: 27 mm [range, 25-27 mm]). Compared with the TAV group, the BAV group had a shorter hospital stay (6 days vs 7 days; P = .001) but similar 30-day mortality (1.8% vs 1.2%). The BAV group had better long-term (15-year) survival (46% vs 33%; P = .002) but a higher cumulative incidence of reoperation for structural valve deterioration (15-year: 15% vs 11%; P = .048). Cox proportional hazard analysis identified a BAV as a protective factor for long-term mortality (hazard ratio [HR], 0.71; 95% CI, 0.56-0.91; P = .006), but a risk factor for reoperation due to structural valve deterioration (HR, 1.4 [95% CI, 0.8-2.6; P = .27] in the matched cohort and 2.2 [95% CI, 1.3-3.7; P = .004] in the unmatched cohort).

Conclusions: The BAV patients had better long-term survival but a higher reoperation rate compared with TAV patients after stentless AVR. Our findings suggest caution in the use of bioprostheses for BAV patients.

Keywords: AVR, aortic valve replacement; BAV, bicuspid aortic valve; CI, confidence interval; HR, hazard ratio; NDI, National Death Index; OR, odds ratio; SAVR, surgical aortic valve replacement; TAV, tricuspid aortic valve; TAVR, transcatheter aortic valve replacement; aortic valve replacement; bicuspid aortic valve; bioprosthesis; long-term survival; reoperation; stentless valve.

Graphical abstract

Patients with a BAV had better long-term survival but a higher rate of reoperation than patients with a TAV after stentless AVR.

Figure 1

Kaplan–Meier long-term survival of propensity score–matched bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients. Ten-year survival was 72% (95% confidence interval [CI], 65%-77%) for the BAV group versus 59% (95% CI, 52%-65%) for the TAV group. Fifteen-year survival was significantly better in the BAV group (46% [95% CI, 38%-54%] vs 33% [95% CI, 26%-41%]).

Figure 2

Cumulative incidence of reoperation for valve deterioration (with death and other reasons for reoperation as competing factors) among propensity score–matched bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients following aortic valve replacement. The 15-year cumulative incidence of reoperation was 15% (95% confidence interval [CI], 10%-22%) for the BAV group versus 11% (95% CI, 6.4%-17%) for the TAV group.

Figure 3

Ten-year cumulative incidence of reoperation with 95% confidence interval (CI), adjusting for death and other causes of reoperation besides structural factors as competing factors (see Methods), owing to structural valve deterioration at 10 years by age for bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients in the propensity score–matched cohort.

Figure 4

Summary of the study describing the propensity score–matched cohort of bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients undergoing stentless aortic valve replacement, with long-term survival and reoperation outcomes and implications. Long-term survival was significantly better in the BAV patients; however, they also had higher rates of reoperation.

Figure E1

Illustration of the modified inclusion operative technique. Different from the figure, in our cohort, we scalloped the left and right coronary sinus of the Freestyle porcine aortic root instead of the noncoronary sinus.

Figure E2

Kaplan–Meier long-term survival of the entire unmatched cohort of bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients. The 10-year survival was 78% (95% confidence interval [CI], 74%-81%) for the BAV group versus 53% (95% CI, 49%-57%) for the TAV group. The 15-year survival was significantly better in the BAV group compared with the TAV group (57% [95% CI, 51%-63%] vs 27% [95% CI, 22%-31%]).

Figure E3

Cumulative incidence of reoperation for valve deterioration (with death and other reasons for reoperation as competing factors) in the whole unmatched cohort of bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients following aortic valve replacement. The 15-year cumulative incidence of reoperation was 15% (95% confidence interval (CI), 12%-19%) for the BAV group versus 6.0% (95% CI, 3.8%-9.0%) for the TAV group.

Figure E4

Ten-year cumulative incidence of reoperation with 95% confidence intervals (CI), adjusting for death and other competing factors (see Methods), owing to structural valve deterioration at different ages for bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients in the whole unmatched cohort.