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Adverse Aortic Events After Isolated Aortic Valve Replacement For Bicuspid Aortic Valve Insufficiency And Concomitant Aortic Root Dilation
Evaldas Girdauskas1, Kushtrim Disha1, Mina Rouman1, Michael Andrew Borger2, Thomas Kuntze1.
1Central Hospital Bad Berka, Bad Berka, Germany, 2Heart Center Leipzig, Leipzig, Germany.

Objective: The optimal treatment of patients with distinct forms of bicuspid aortic valve (BAV) associated aortopathy is insufficiently defined. The aim of this study was to evaluate the risk of late aortic events after isolated aortic valve replacement (AVR) for BAV insufficiency with concomitant mild to moderate dilation of aortic root (i.e., root phenotype).
Methods: Review of our institutional BAV database (n=510 patients) identified a subgroup of 56 (11%) consecutive patients (mean age 47±11 years, 95% men) with a BAV insufficiency and concomitant aortic root diameter of 40-50 mm (i.e., root phenotype), who underwent isolated AVR from 1995 through 2008. All these patients had a significant aortic annular dilation (i.e., defined as valve prosthesis size >27mm) and showed no relevant transvalvular gradient (i.e., mean pressure gradient <20 mmHg). All cases of simultaneous aortic surgery (i.e. with diameter of aortic root >50mm) were excluded. Follow-up (516 patient-years) was 100% complete. Adverse aortic events were defined as the need for proximal aortic surgery / redo-AVR for late paravalvular leakage, the occurrence of aortic dissection/rupture, or sudden death during follow-up.
Results: Actuarial survival rates of our study population were 91% and 78% at 10 and 15 years, respectively. Adverse aortic events occurred in 10 (18%) study patients during follow-up. Proximal aortic surgery was required in 3 study patients (5%) and three (5%) additional patients underwent redo-AVR due to late paravalvular leakage. Two cases (4%) of documented type A aortic dissection occurred. A total of 4 patients (7%) suffered sudden cardiac death during follow-up. Freedom from adverse aortic events was 87% at 10 years and 47% at 15 years postoperatively. In a group of BAV patients presenting with aortic valve stenosis and concomitant mild to moderate dilation of tubular ascending aorta, freedom from adverse aortic events was significantly higher (95% and 93% at 10 and 15 years, p<0.001).
Conclusions: BAV patients with aortic valve insufficiency and concomitant aortic root dilation of 40-50 mm are at significant risk of adverse aortic events at 15 years after isolated AVR. Simultaneous aortic root surgery should be strongly considered in these BAV patients during their initial AVR.

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