Risk Of Adverse Aortic Events Research Articles

Fate of the distal aorta following root replacement in Marfan syndrome: a propensity score matched study.

The aortic root is the most frequent segment involved in Marfan syndrome. However, Marfan syndrome is a systemic hereditary connective tissue disorder, and knowledge regarding the outcomes of the native distal aorta after prophylactic aortic root surgery is limited. From April 2010 to December 2020, 226 patients with Marfan syndrome and 1,200 patients without Marfan syndrome who underwent Bentall procedures were included in this study. By propensity score matching, 134 patients were assigned to each group. Clinical manifestations and follow-up data were acquired from hospital records and telephone contact. The cumulative incidence of aortic events was estimated in Marfan and non-Marfan patients with death as a competing risk. Patients with and without Marfan syndrome had similar baseline characteristics after propensity score matching. Differences in the aortic root (62.25 ± 11.96 vs. 54.03 ± 13.76, P < .001) and ascending aorta (37.71 ± 9.86 vs. 48.16 ± 16.01, P < .001) remained after matching. No difference was observed in the frequency of aortic adverse events between the two groups (10.5% vs. 4.6%, P = 0.106). The cumulative incidence of aortic events was not different between Marfan and non-Marfan patients (15.03% ± 4.72% vs. 4.18% ± 2.06%, P = 0.147). Multivariate Cox regression indicated no significant impact of Marfan syndrome on distal aortic events (HR: 1.172, 95% CI: 0.263-5.230, P = 0.835). Descending and abdominal aortic diameter above normal at the initial procedure were associated with the risk of distal aortic events (HR: 20.735, P = .003, HR: 22.981, P = .002, respectively). New-onset events of the residual aorta in patients undergoing Bentall procedures between the Marfan and non-Marfan groups were not significantly different. Distal aortic diameter above normal at initial surgery was associated with a higher risk of adverse aortic events.

Risk evaluation of adverse aortic events in patients with non-circular aortic annulus after transcatheter aortic valve implantation: a numerical study.

Transcatheter aortic valve implantation (TAVI) is a micro-invasive surgery used to treat patients with aortic stenosis (AS) efficiently. However, the uneven valve expansion can cause a non-circular annulus, which is one of the main factors leading to complications after TAVI. As a preliminary work, the main purpose of this study was to evaluate the risk of adverse aortic events in patients with a non-circular aortic annulus after TAVI. This study numerically investigated the distribution of four wall shear stress (WSS)-based indicators and three helicity-based indicators in eight patient-specific aortas with different annulus including circular, type I elliptical and type II elliptical shapes. Both elliptical annulus features can significantly enhance the intensity of the helicity (h2) in the ascending aorta (p < 0.001). However, for the type I elliptical annulus, the spiral flow structure was changed into low-velocity and disturbed flow pattern close to the inner side of the aortic arch. For the type II elliptical annulus, the spiral flow remained but became skewed in distribution. The elliptical annulus feature could increase the general level WSS-based indicators, especially in the ascending aorta. However, due to the disturbance of spiral flow or second helical flow in ascending aortas, areas with low TAWSS accompanied by high oscillatory shear index (OSI) and cross flow index (CFI) were observed in all the ascending aortas with non-circular annulus. The elliptical annulus feature can change the hemodynamic environment in the aortic arch, especially in the ascending aorta. Although both elliptical annulus features enhanced the strength of helicity, the uniform distribution of the helical flow was disturbed, especially in the ascending aorta, indicating the potential risk of adverse aortic events may increase. Therefore, for the patients without paravalvular leak but elliptical annulus shape after TAVI treatment, surgeons may be needed to consider further dilatation to make the non-circular annulus become circular.

Prognosis of Unrepaired Ascending Aorta after the Surgical Replacement of Bicuspid Aortic Valves.

The surgical threshold for bicuspid aortic valve (BAV)-related aortopathy is a matter of debate due to its uncertain etiology and prognosis. This study investigated the prognosis of unrepaired BAV aortopathy in patients undergoing surgical aortic valve replacement (SAVR). We retrospectively analyzed data from 720 patients (age, 60.8±11.5 years; 246 women) who underwent SAVR for BAV disease without aortic repair between 2005 and 2020 at Asan Medical Center. The clinical endpoints were defined as occurrences of sudden death, aortic dissection or rupture, and elective aortic repair. To estimate postoperative changes in the dimensions of the unrepaired aorta, the individual annual aortic expansion rate was calculated. Multiple linear regression models were used to evaluate the risk of aortic expansion. The mean ascending aortic diameter was 39.5±4.6 mm, and 299 patients (41.5%) had a baseline ascending aorta diameter >40 mm. During 70.0±68.3 months of follow-up, the mean annual aortic expansion rate was 0.39±1.96 mm/yr, no aortic dissection or rupture was observed, and sudden deaths were reported in 12 patients (0.34% per person-year). Linear regression analysis revealed no significant correlation between the baseline ascending aortic diameter and postoperative aortic expansion (R2=0.004, β=-0.84, p=0.082). In selected patients undergoing SAVR for a BAV (<55 mm), the risk of adverse aortic events was very low. As this observation contradicts current practice guidelines advocating for proactive aortic replacement in dilated ascending aortas measuring >45 mm, the study results need further validation by studies involving larger populations or randomized controlled trials.

Bicuspid aortopathy does not require earlier surgical intervention

ObjectivesGuidelines for surgical correction of patients with ascending thoracic aortic aneurysm (ATAA) with a bicuspid aortic valve (BAV) have oscillated over the years. In this study, we outline the natural history of the ascending aorta in patients with BAV and trileaflet aortic valve (TAV) ATAA followed over time, to ascertain if their behavior differs and to determine if a different threshold for intervention is required. MethodsAortic diameters and long-term complications (ie, adverse aortic events) of 2428 patients (554 BAV and 1874 TAV) with ATAA before operative repair were reviewed. Growth rates, yearly complication rates, event-free survival, and risk of complications as a function of aortic size were calculated. Long-term follow-up and precise cause of death granularity was achieved via a comprehensive 6-pronged approach. ResultsAortic growth rate in patients with BAV vs TAV ATAA was 0.20 and 0.17 cm/year, respectively (P = .009), with the rate increasing with increasing aortic size. Yearly adverse aortic events rates increased with ATAA size and were lower for patients with BAV. The relative risk of adverse aortic events exhibited an exponential increase with aortic diameter. Patients with BAV had a lower all-cause and ascending aorta-specific adverse aortic events hazard. Age-adjusted 10-year event-free survival was significantly better for patients with BAV, and BAV emerged as a protective factor against type A dissection, rupture, and ascending aortic death. ConclusionsThe threshold for surgical repair of ascending aneurysm with BAV should not differ from that of TAV. Prophylactic surgery should be considered at 5.0 cm for patients with TAV (and BAV) at expert centers.

Fate of the unoperated ascending thoracic aortic aneurysm: three-decade experience from the Aortic Institute at Yale University.

This study aims to outline the 'true' natural history of ascending thoracic aortic aneurysm (ATAA) based on a cohort of patients not undergoing surgical intervention. The outcomes, risk factors, and growth rates of 964 unoperated ATAA patients were investigated, over a median follow-up of 7.9 (maximum of 34) years. The primary endpoint was adverse aortic events (AAE), including dissection, rupture, and aortic death. At aortic sizes of 3.5-3.9, 4.0-4.4, 4.5-4.9, 5.0-5.4, 5.5-5.9, and ≥6.0 cm, the average yearly risk of AAE was 0.2%, 0.2%, 0.3%, 1.4%, 2.0%, and 3.5%, respectively (P < 0.001), and the 10-year survival free from AAE was 97.8%, 98.2%, 97.3%, 84.6%, 80.4%, and 70.9%, respectively (P < 0.001). The risk of AAE was relatively flat until 5 cm of aortic size, at which it began to increase rapidly (P for non-linearity <0.001). The mean annual growth rate was estimated to be 0.10 ± 0.01 cm/year. Ascending thoracic aortic aneurysms grew in a very slow manner, and aortic growth over 0.2 cm/year was rarely seen. Multivariable Cox regression identified aortic size [hazard ratio (HR): 1.78, 95% confidence interval (CI): 1.50-2.11, P < 0.001] and age (HR: 1.02, 95% CI: 1.00-1.05, P = 0.015) as significant independent risk factors for AAE. Interestingly, hyperlipidemia (HR: 0.46, 95% CI: 0.23-0.91, P = 0.025) was found to be a significant protective factor for AAE in univariable Cox regression. An aortic size of 5 cm, rather than 5.5 cm, may be a more appropriate intervention criterion for prophylactic ATAA repair. Aortic growth may not be an applicable indicator for intervention.

Aortic Dilatation in Patients With Bicuspid Aortic Valve.

Bicuspid aortic valve (BAV) is the most common congenital cardiac abnormality. BAV aortic dilatation is associated with an increased risk of adverse aortic events and represents a potentially lethal disease and hence a considerable medical burden. BAV with aortic dilatation warrants frequent monitoring, and elective surgical intervention is the only effective method to prevent dissection or rupture. The predictive value of the aortic diameter is known to be limited. The aortic diameter is presently still the main reference standard for surgical intervention owing to the lack of a comprehensive understanding of BAV aortopathy progression. This article provides a brief comprehensive review of the current knowledge on BAV aortopathy regarding clinical definitions, epidemiology, natural course, and pathophysiology, as well as hemodynamic and clinically significant aspects on the basis of the limited data available.

Marfan Syndrome Versus Bicuspid Aortic Valve Disease: Comparative Analysis of Obstetric Outcome and Pregnancy-Associated Immediate and Long-Term Aortic Complications.

Pregnancy poses a threat to women with aortopathy. Conclusive data on the obstetric and aortic outcome in this risk collective, especially when it comes to aortic complications in the long term, are still missing. This study offers a comparative analysis of pregnancy-associated outcome in 113 consecutive women with Marfan syndrome or bicuspid aortic valve disease, including 46 ever-pregnant and 37 never-pregnant women with Marfan syndrome, and 23 ever-pregnant and 7 never-pregnant females with bicuspid aortic valve disease. The overall obstetric outcome was comparable between ever-pregnant women with Marfan syndrome and with bicuspid aortic valve disease (p = 0.112). Pregnancy-associated aortic dissection occurred in two women with Marfan syndrome (3%) during a total of 62 completed pregnancies, whereas no single case of aortic event occurred in women with bicuspid aortic valve disease during a total of 36 completed pregnancies (p = 0.530). In the long-term follow-up, aortic dissection occurred in 21% of ever-pregnant women with Marfan syndrome, but in none of the women with bicuspid aortic valve disease (p = 0.022). Proximal aortic surgery was performed with similar frequency in ever-pregnant women with Marfan syndrome and with bicuspid aortic valve disease in the long term (p = 0.252). However, ever-pregnant women with Marfan syndrome were younger when surgery was performed (44 ± 9 vs. 59 ± 7 years; p = 0.041). In Marfan syndrome, long-term growth of the aorta was comparable between ever-pregnant and never-pregnant women. Pregnancy thus exhibited an increased immediate aortic risk only in women with Marfan syndrome, but not in women with bicuspid aortic valve disease. Previous pregnancy did not relate to an increased long-term risk of adverse aortic events in women with Marfan syndrome or with bicuspid aortic valve disease.

Evaluation of microribonucleic acids as potential biomarkers in the bicuspid aortic valve-associated aortopathy.

We aimed to evaluate the impact of microRNAs to predict the bicuspid aortic valve (BAV)-associated aortopathy. Sixty-three BAV patients (mean age 47 ± 11 years, 92% men) with root dilatation, who underwent aortic valve ± proximal aortic surgery (mean post-AVR follow-up 10.3 ± 6.9 years) were included. The BAV aortopathy entities were categorized in the 'less dilated' (aortic root <50 mm) and 'severely dilated' (aortic root ≥50 mm) aorta. Several microRNAs were assessed using polymerase chain reaction. End-points were the correlation between microRNAs and severity of aortopathy/prevalence of adverse aortic events. Circulating levels of miR-17 and miR-106a were strongly correlated (r = 0.84, P < 0.001). Our analysis yielded significantly higher values of miR-17 (delta Ct 2.09 ± 0.64 vs delta Ct 1.68 ± 0.64, P = 0.02) and miR-106a (delta Ct 5.88 ± 0.43 vs delta Ct 5.61 ± 0.60, P = 0.046) in BAV patients with the less dilated versus the severely dilated aorta. miR-17 (delta Ct 1.51 ± 0.73 vs delta Ct 2.00 ± 0.61, P = 0.02) and miR-106a (delta Ct 5.39 ± 0.69 vs delta Ct 5.85 ± 0.44, P = 0.007) were significantly downregulated in BAV patients who experienced adverse aortic events. Expression of circulating miR-17 and miR-106a in the BAV root phenotype patients correlates with the severity of aortopathy and the risk of adverse aortic events. MicroRNAs have the potential to serve as biomarkers in the BAV-associated aortopathy.

Are normal-sized ascending aortas at risk of late aortic events after aortic valve replacement for bicuspid aortic valve disease?

Bicuspid aortic valve (BAV)-associated aortopathy has been proposed to progress after isolated aortic valve replacement (AVR) surgery, which has been traditionally used as an argument against a TAVR procedure in this clinical subset. Still, more than half of BAV patients have a normal-sized proximal aorta at the time of AVR surgery. We aimed to analyse the long-term risk of adverse aortic events after isolated conventional AVR surgery for BAV and normal-sized proximal aorta. A total of 200 consecutive patients (mean age 56 ± 13 years, 73% men) with BAV disease and ascending aortic diameter of <40 mm underwent isolated conventional AVR from 1995 through 2008 and were identified from our institutional BAV database. Long-term follow-up data (a total of 1532 patient-years) were obtained for all hospital survivors. Composite adverse aortic/cardiovascular events were defined as the need for redo aortic surgery, the occurrence of aortic dissection/rupture, or sudden cardiac death during follow-up. A total of 25 (13%) patients died after a mean follow-up of 8.5 ± 5 years post-AVR surgery, which resulted in an overall survival rate of 75 ± 6 and 87 ± 7% at 15 years postoperatively, for BAV-aortic stenosis and BAV-aortic regurgitation, respectively (P = 0.6). An adverse aortic event occurred in 1 (0.5%) study patient, while 5 (2.5%) further patients suffered sudden cardiac death. Only 1 patient required redo aortic surgery. No documented aortic dissection/rupture occurred. Redo AVR surgery due to endocarditis or structural valve degeneration was performed in 6 (3%) patients. The rate of freedom from composite adverse events was 92 ± 5 and 95 ± 4% at 15 years, for the AS and AR subgroups, respectively (P = 0.7). BAV patients with aortic valve dysfunction and normal-sized ascending aorta are at considerably low risk of late adverse aortic events after isolated AVR.

Aortic events after isolated aortic valve replacement for bicuspid aortic valve root phenotype: echocardiographic follow-up study.

Various forms of bicuspid aortic valve (BAV) aortopathy exist, and the optimal treatment for the different subgroups is insufficiently defined. We aimed to analyse the risk of adverse aortic events after aortic valve replacement (AVR) for BAV insufficiency and concomitant mild-to-moderate dilatation of the aortic root (i.e. BAV root phenotype). A total of 56 consecutive patients (mean age 47 ± 11 years, 95% men) with BAV insufficiency and a root diameter of 40-50 mm underwent AVR surgery from 1995 to 2008. All patients, as identified from our institutional BAV database, had a dilated aortic annulus (i.e. defined as valve prosthesis size ≥27 mm) without aortic stenosis (i.e. mean gradient ≤20 mmHg). Patients who underwent concomitant aortic surgery were excluded. Follow-up (622 patient-years) including echocardiography data was available for all patients. Aortic events were defined as the need for proximal aortic surgery, the occurrence of aortic dissection/rupture, echocardiographic evidence of increasing aortic root diameter/occurrence of late paravalvular leakage or sudden death during follow-up. Actuarial survival was 90% at 10 years and 78% at 15 years. Adverse aortic events occurred in 19 (34%) study patients. Redo aortic surgery was performed in 6 patients (11%), 2 of which were for aortic dissection. Four patients (7%) suffered sudden cardiac death. Moreover, follow-up echocardiography revealed a significant, progressive enlargement of the aortic root diameter in 7 (13%) patients and occurrence of late de novo paravalvular leakage in 2 (3%) patients. The resultant freedom from aortic events was 81% at 10 years and 51% at 15 years. Patients with a BAV root phenotype are at significant risk of aortic events after isolated AVR. Simultaneous root/ascending aortic surgery should be strongly considered in such patients.

Bicuspid aortic valve disease and ascending aortic aneurysm: should an aortic root replacement be mandatory?†.

The higher risk of adverse aortic events in patients with bicuspid aortic valve (BAV) disease and ascending aorta aneurysm is known, but the management of moderate aortic root dilatation in younger patients is a controversial issue. The aim of the study was to compare survival in patients with or without root replacement. We reviewed 166 consecutive patients with BAV disease and concomitant ascending aorta aneurysm (mean ascending aorta diameter: 51.4 ± 7.2 mm) undergoing cardiac surgery from 1994 to 2010. A total of 77 patients underwent Bentall procedure (90.9% male, mean age: 55.7 ± 12.7 years, Bentall group), whereas the remaining 89 patients underwent aortic valve replacement with supracoronary ascending aorta replacement (SAAR 71.9% male, mean age: 60.5 ± 11.2 years, SAAR group, P = 0.002). The preoperative mean diameter of the root was 44.0 ± 7.2 mm in the Bentall, and 38.5 ± 4.8 mm in the SAAR group (P < 0.0001). In-hospital mortality was 2.6% in the Bentall, and 2.3% in the SAAR groups. Overall survival was 84 and 81% in the Bentall (median follow-up: 105 months) versus 89 and 88% in the SAAR (median follow-up: 73 months) groups at 10 and 15 years (P = 0.36), respectively. The mean cardiopulmonary bypass (CPB) time was 201 ± 56 min and 174 ± 58 min (P = 0.0016), the mean cross-clamp time 156 ± 42 min and 132 ± 38 min (P = 0.0008) in the Bentall and SAAR groups, respectively. Four sudden deaths have occurred in the Bentall group and in 2 in the SAAR group. Progressive dilatation of the aortic root in the SAAR group was not significat (postoperative mean diameter: 36.3 ± 4.4 mm). Neither subgroup of patients in the SAAR with preoperative moderate dilatation of aortic root had significat aortic dilatation at the mean follow-up of 73 ± 39 months (preoperative diameter: 43.5 ± 2.3 mm versus postoperative: 39.1 ± 4.2 mm). One patient in Bentall and 1 in the SAAR groups were reoperated for tubular graft infection. In patients with BAV disease, ascending aorta aneurysm and moderate dilatation of the root, the significat reduction of CPB and cross-clamp times, the stability of the residual root at long term and the low risk of adverse aortic events associated with SAAR compared with the Bentall procedure have led us to consider the isolated aortic valve replacement with supracoronary aorta replacement an alternative strategy to the Bentall procedure, especially in high-risk and older patients.

184 * BICUSPID AORTIC VALVE DISEASE AND ASCENDING AORTIC ANEURYSM: SHOULD THE AORTIC ROOT REPLACEMENT BE MANDATORY?

OBJECTIVES: The higher risk of adverse aortic events in patients with bicuspid aortic valve (BAV) disease and ascending aorta aneurysm is known, but the management of moderate aortic root dilatation in younger patients is a controversial issue. The aim of the study was to compare survival in patients with or without root replacement. METHODS: We reviewed 166 consecutive patients with BAV disease and concomitant ascending aorta aneurysm (mean ascending aorta diameter: 51.4 ± 7.2 mm) undergoing cardiac surgery from 1994 to 2010. A total of 77 patients underwent Bentall procedure (90.9% male, mean age: 55.7 ± 12.7 years, Bentall group), whereas the remaining 89 patients underwent aortic valve replacement with supracoronary ascending aorta replacement (SAAR 71.9% male, mean age: 60.5 ± 11.2 years, SAAR group, P= 0.002). The preoperative mean diameter of the root was 44.0 ± 7.2 mm in the Bentall, and 38.5 ± 4.8 mm in the SAAR group (P< 0.0001). RESULTS: In-hospital mortality was 2.6% in the Bentall, and 2.3% in the SAAR groups. Overall survival was 84 and 81% in the Bentall (median follow-up: 105 months) versus 89 and 88% in the SAAR (median follow-up: 73 months) groups at 10 and 15 years (P= 0.36), respectively. The mean cardiopulmonary bypass (CPB) time was 201 ± 56 min and 174 ± 58 min (P= 0.0016), the mean cross-clamp time 156 ± 42 min and 132 ± 38 min (P= 0.0008) in the Bentall and SAAR groups, respectively. Four sudden deaths have occurred in the Bentall group and in 2 in the SAAR group. Progressive dilatation of the aortic root in the SAAR group was not significat (postoperative mean diameter: 36.3 ± 4.4 mm). Neither subgroup of patients in the SAAR with preoperative moderate dilatation of aortic root had significat aortic dilatation at the mean follow-up of 73 ± 39 months (preoperative diameter: 43.5 ± 2.3 mm versus postoperative: 39.1 ± 4.2 mm). One patient in Bentall and 1 in the SAAR groups were reoperated for tubular graft infection. CONCLUSIONS: In patients with BAV disease, ascending aorta aneurysm and moderate dilatation of the root, the significat reduction of CPB and cross-clamp times, the stability of the residual root at long term and the low risk of adverse aortic events associated with SAAR compared with the Bentall procedure have led us to consider the isolated aortic valve replacement with supracoronary aorta replacement an alternative strategy to the Bentall procedure, especially in high-risk and older patients.

Transcatheter aortic valve implantation in patients with ascending aortic dilatation: safety of the procedure and mid-term follow-up

Transcatheter aortic valve implantation (TAVI) does not enable concomitant or simultaneous ascending aortic intervention. This investigation evaluates the safety of TAVI in patients with ascending aortic dilatation and demonstrates mid-term follow-up. From November 2007 to December 2012, among 1143 patients with severe aortic stenosis screened for TAVI, a cohort of 457 patients met the inclusion criteria. Of these, a total of 98 patients [71% males, median age 85.0 (9.0) years] were diagnosed with concomitant ascending aortic dilatation (4.0-5.0 cm). An additional 2 patients had an ascending aortic diameter of >5.0 cm. The mid-term follow-up (652.2 patient-years) was 100% complete. There was no iatrogenic dissection in patients with dilatated ascending aorta. Intraoperative aortic rupture occurred in 1 patient with mildly dilatated ascending aorta. One-year survival rates in patients with dilatated and non-dilatated ascending aorta were 65 of 75 (87%) and 201 of 242 (83%, P = 0.573). The mean ascending aortic diameter remained stable at 4.1 (0.2) and 4.7 (0.2) cm in patients with mild and moderate dilatation, respectively, with a median follow-up of 14 months after TAVI. Two patients with an aortic diameter of over 5.0 cm survived the procedure and expired 7 and 20 months after TAVI due to tumour and heart failure, respectively. Ascending aortic dilatation is diagnosed in almost one-fourth of patients treated with TAVI. Their intraprocedural risk of adverse aortic events is low. The ascending aortic dilatation does not affect mid-term survival in the TAVI population.

Reply to Lee

Reply to Lee

Reply to Dayan et al.

I would like to thank Dayan et al. for their insightful comments [1] on our recently published manuscript [2]. Moreover, Dayan et al. should be congratulated for their own contributions in the field of BAV-associated aortopathy [3, 4]. The above-discussed manuscript does not give definite answer to the question of predictors for proximal aortic dilatation after AVR surgery in BAV patients [2]. Our multivariate analysis was based on eight (5%) clinically relevant adverse aortic events, which inherently limit the number of variables, which may be reasonably included in the regression analysis. We did not include the variable ‘BAV configuration’ in our statistical analysis, as this morphological information was available retrospectively in only 55% of our study population (i.e. 84 of 152 patients). In contrast to the findings of Dayan et al. [4], we did not find any significant correlation between the body surface area (BSA), family history of BAV and the increased risk of adverse aortic events in our study. One possible explanation for this discrepancy may be the inclusion of BAV patients with an isolated/predominant aortic valve insufficiency (i.e. 17% of the study cohort) in the series of Dayan et al. [3]. This specific subgroup of BAV patients, which may be also defined as a ‘root phenotype’, is predominantly male (i.e. larger BSA) and have often a strong family history of BAV/aortopathy [5]. Recent data from the literature indicate significantly increased risk of late adverse aortic events in this specific cohort of BAV patients after isolated AVR [6]. There is emerging evidence that this phenotype of BAV disease may represent a predominantly congenital/ genetic form of BAV/aortopathy [5]. The inclusion of BAV patients with a ‘root phenotype’ in the study of Dayan et al. [4] may reasonably explain the progression of aortic root dimensions late after AVR surgery and the observed correlations with the BSA as well as with the family history of BAV/aortopathy. In contrast to that, we included only BAV patients with an isolated/predominant aortic valve stenosis [2]. Unfortunately, our study was not designed to specifically analyse the protective effects of long-term pharmacological treatment (i.e. effects of beta-blockers and statins). The vast majority of our patients (i.e. 95% of the study cohort) underwent long-term beta-blocker therapy after AVR, whereas only very few of them received statins. Therefore, we were not able to reasonably include these variables in our Cox regression model. Dayan et al. [4] found recently some positive effects of betablocker/statin use in the BAV patients in preventing aortic root dilatation between 6 and 8 years after an isolated AVR. However, such data should be interpreted with a caution. Only a small proportion of the initial study cohort received pharmacological treatment postoperatively (i.e. 11 (18%) patients with betablockers and 8 (13%) patients with statins postoperatively) [3]. Moreover, only 23 of 60 (38%) patients of the initial study cohort underwent an echocardiographical follow-up examination at 8 years post-AVR [4]. This would result in a very limited number of pharmacologically treated BAV patients at 8 years post-AVR. In summary, the protective effect of long-term betablocker/statin therapy in BAV-associated aortopathy is still unclear and should be addressed in future by means of largescale prospective studies.

Long-term prognosis of ascending aortic aneurysm after aortic valve replacement for bicuspid versus tricuspid aortic valve stenosis

The bicuspid aorta is thought to have a higher risk of progressive dilation after aortic valve replacement with a subsequently increased risk of adverse aortic events. Our aim was to compare the risk of late aortic events after isolated aortic valve replacement surgery for bicuspid versus tricuspid aortic valve stenosis with concomitant mild to moderate dilatation of the proximal aorta. A total of 325 consecutive patients (60% males; mean age, 59.5 ± 10 years) with aortic valve stenosis and concomitant ascending aortic dilatation of 40 to 50 mm underwent isolated aortic valve replacement from 1995 through 2000. A total of 153 patients (47%) were diagnosed with bicuspid aortic valve stenosis (bicuspid aortic valve group), whereas the remaining 172 patients (53%) had tricuspid aortic valve stenosis (tricuspid aortic valve group). Follow-up (3566 patient-years) was 100% complete. Adverse aortic events were defined as the need for proximal aortic surgery or the occurrence of aortic dissection/rupture or sudden death during follow-up. Overall survival was 78 ± 4% in the bicuspid aortic valve group versus 55 ± 6% in the tricuspid aortic valve group (P=.006) at 15 years postoperatively, but age-adjusted survival was not significantly different between groups (P=.4). A total of 5 patients (3%) in the bicuspid aortic valve group versus 9 patients (5%) in the tricuspid aortic valve group underwent proximal aortic surgery during follow-up. Aortic dissection occurred in 3 patients in the tricuspid aortic valve group and in no bicuspid aortic valve patients. Fifteen-year freedom from adverse aortic events was 93 ± 3% in the bicuspid aortic valve group versus 82 ± 6% in the tricuspid aortic valve group (P=.2). Patients with bicuspid and tricuspid aortic valve stenosis with concomitant mild to moderate ascending aortic dilatation are at comparably low risk of adverse aortic events 15 years after isolated aortic valve replacement.

Risk of late aortic events after an isolated aortic valve replacement for bicuspid aortic valve stenosis with concomitant ascending aortic dilation

The optimal surgical treatment of patients with bicuspid aortic valve (BAV) disease and ascending aortic aneurysm is controversial. The aim of this study was to evaluate the risk of late aortic events after an isolated aortic valve replacement (AVR) for BAV stenosis with concomitant mild-to-moderate proximal aortic dilation. A review of our institutional BAV database identified a subgroup of 153 consecutive BAV patients (mean age 54.2 ± 10.5 years, 73% men) with BAV stenosis and concomitant ascending aortic dilation of 40-50 mm who underwent an isolated AVR from 1995 to 2000. All cases of simultaneous aortic surgery (i.e. ascending aorta with a diameter of >50 mm) were excluded. The follow-up (1759 patient-years) was 100% complete. The mean follow-up was 11.5 ± 3.2 years. Adverse aortic events were defined as the need for proximal aortic surgery, the occurrence of aortic dissection/rupture or sudden death during the follow-up. Actuarial survival rates of our study population were 86 and 78% at 10 and 15 years, respectively. Ascending aortic surgery was required in five patients (3%) for progressive ascending aortic aneurysm. Freedom from aortic interventions at 10 and 15 years was 97 and 94%, respectively. No documented aortic dissection or rupture occurred. Freedom from adverse aortic events was 95% at 10 years and 93% at 15 years postoperatively. In a separate group of patients presenting with aortic insufficiency (i.e. root phenotype), freedom from adverse aortic events was significantly lower (88 and 70% at 10 and 15 years, P = 0.009). BAV patients with aortic valve stenosis and concomitant mild-to-moderate ascending aortic dilation are at a considerably low risk of adverse aortic events at 15 years after an isolated AVR. The BAV phenotype should be considered when determining the risk of subsequent adverse aortic events and the need for concomitant aortic replacement.