Surg Today DOI 10.1007/s00595-015-1274-4
ORIGINAL ARTICLE
Long‑term results after treatment of the ascending aorta for bicuspid aortic valve patients Sho Matsuyama1 · Takahiro Nishida1 · Tomoki Ushijima1 · Ryuji Tominaga1
Received: 3 June 2015 / Accepted: 21 July 2015 © Springer Japan 2015
Abstract Purpose We evaluated the long-term results of aortic valve replacement for bicuspid aortic valve patients with or without surgical treatment of the ascending aorta. Methods A total of 145 bicuspid aortic valve patients had undergone aortic valve replacement since 1974 at our institution. No surgical treatment (Group-N; n = 115) was performed in the ascending aorta if the diameter was less than 40 mm. We wrapped an ascending aorta of 40–50 mm with an artificial graft (Group-W; n = 19), and performed replacement (Group-R; n = 11) if the ascending aorta measured more than 50 mm. Follow-up was completed for 144 patients (99.3 % of the cases). Results The hospital mortality rate was 1.4 %. There were no significant differences among Groups N, W and R in the freedom from valve-related death and cardiac death at 10 years after surgery. The rates of freedom from aortarelated events in the three groups at 10 years after surgery were 98.3 % (Group-N), 100 % (Group-W) and 100 % (Group-R). Conclusions The long-term survival was equivalent among the three groups, and the rates of freedom from aorta-related death or events were low. Our surgical protocol for the treatment of the enlarged ascending aorta associated with BAV is appropriate. Keywords Aortic operation · Bicuspid aortic valve · Aortic valve replacement · CHD in adults
Introduction A bicuspid aortic valve (BAV) is the most common congenital cardiac anomaly in adults, and affects 0.5–2.0 % of the population [1, 2]. Aortic stenosis (AS) and regurgitation (AR) are the most common complications of BAV, and bicuspid aortopathy, dilation of the ascending aorta, occurs in about one-half of BAV patients [2]. Reports have described several causes of bicuspid aortopathy, including hemodynamic derangements of the BAV [3, 4], histological abnormalities of the aortic media in BAV patients (including cystic medial necrosis and abnormal fibrillin-1) [5] and increased matrix metalloproteinase activity [6]. Ascending aortic events, including aortic dissection and aortic aneurysm rupture, generally cause catastrophic results. Therefore, it is important to prevent aortic events due to bicuspid aortopathy in BAV patients by improving the long-term results after aortic valve replacement (AVR). In general, the recent guidelines have recommended aortic replacement for BAV patients who have ascending aortic aneurysms greater than 45–50 mm in diameter [7]. However, the most appropriate criteria for aortic intervention for bicuspid aortopathy are still controversial. The purpose of this study was to analyze our 30-year clinical experience with aortic intervention for BAV patients in order to clarify the optimal management for bicuspid aortopathy.
Patients and methods * Takahiro Nishida [email protected]‑u.ac.jp 1
Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, 3‑1‑1 Maidashi, Higashi‑ku, Fukuoka 812‑8582, Japan
All subjects enrolled in this research have given their informed consent, and this protocol has been approved by the institutional committee on human research. Between
13
Surg Today
November 25, 1974 and January 7, 2015, 145 patients with BAV underwent AVR with or without an ascending aortic procedure in our institute. A bioprosthesis was used in elderly patients [8, 9] and a mechanical prosthesis was used in younger patients. Our basic policy of surgery for a dilated ascending aorta with BAV is: we perform no intervention on the ascending aorta if the maximum diameter is less than 40 mm, wrapping of the ascending aorta if the maximum diameter is between 40 and 50 mm, and replacement of the ascending aorta if the maximum diameter is more than 50 mm. However, we decided on the surgical procedure both according to this protocol, as well as based on the patient’s age, frailty, complications, etc. As a result, 115 patients had no intervention on the ascending aorta (Group-N), and 19 and 11 patients underwent ascending aorta wrapping (Group-W) and ascending aorta replacement (Group-R), respectively. The main reason for AVR was aortic valve stenosis in 114 patients and aortic regurgitation in 31 patients. Although the durability of newer bioprostheses has been improving [8], mechanical prostheses (97 cases) were mainly used in this study because of the relatively younger age at operation. There were three patients with aortic annular enlargement. Table 1 shows the background and surgical data for the three groups. There were no significant differences among the three groups in terms of the gender, age, New York Heart Association functional class or preoperative left ventricular ejection fraction, although the preoperative maximum ascending aortic diameter was significantly different. The maximum ascending aortic diameter was larger in Group-R than in Groups-N and W. We measured the maximum ascending aortic diameter by a computed tomography (CT) scan, and also by aortogram, transesophageal echocardiography, or actual measurement during surgery if a preoperative CT scan was not available. The details of the operation and patient care were Table 1 Patient backgrounds and surgical data for the three groups
described previously [9, 10]. In brief, all patients underwent surgery with full sternotomy, standard cardiopulmonary bypass and moderate hypothermia (at 28–34 °C). Either cold crystalloid or blood cardioplegia was delivered antegrade, retrograde or both. Everting mattress sutures or horizontal mattress sutures with 2-0 braided polyester reinforced with polytetrafluoroethylene (Teflon) felt pledgets were predominantly used to suture the valves. Aortic wrapping using a vascular prosthesis was performed after AVR. The prosthesis was tailored and placed around the aorta from distal to the sinotubular junction to proximal to the innominate artery, and tightly wrapped with intermittent 3-0 polyester sutures. Circulatory arrest was not used during ascending aortic replacement, including during a Bentall procedure (two cases) and a Wheat procedure (one case). Early postoperative follow-up, followed by monthly or annual follow-up, was performed by us for most of the patients at our outpatient clinic. We directly contacted the patients themselves by interrupting visits, or through their family members or physicians, with questionnaires completed via mail or telephone. When the response to the questionnaire reported the patient’s death, we directly contacted the physician in charge in order to confirm the cause of death and/or related complications. One patient could not be contacted; thus, the follow-up was completed for 99.3 % of the patients, with a total of 1301.5 patient-years (Pt-Yrs). Hospital and late deaths, as well as all valve-related mortalities and complications, were strictly defined according to the published guidelines of the American Association for Thoracic Surgery/The Society of Thoracic Surgeons [11]. All continuous variables are presented as the mean ± standard error of the mean (SEM). Fisher’s exact test and Student’s t tests were used for the univariate analyses. The comparisons among the three groups for the
Group
Group-N
Group-W
Group-R
P value
Number Male (%) Age (years) NYHA Preoperative LVEF (%) Preoperative ascending aortic diameter (mm) Length of operation (min) Cardiopulmonary bypass time (min) Aorta cross-clamp time (min) Bioprosthesis
115 71 (61.7) 59.3 ± 1.5 2.13 ± 0.06 68.7 ± 1.5 37.1 ± 0.7* 349.9 ± 8.92 159.9 ± 5.52 107.3 ± 3.57 33 (28.7 %)
19 12 (70.6) 66.5 ± 2.8 2.00 ± 0.1 69.9 ± 1.7 47.8 ± 0.7 368.9 ± 18.18 164.6 ± 9.58 111.5 ± 7.59 9 (47.4 %)
11 7 (63.6) 53.4 ± 4.2 1.70 ± 0.1 62.3 ± 4.1 55.2 ± 1.6* 395.0 ± 34.1 174.1 ± 20.90 133.5 ± 14.1 6 (54.5 %)
0.7790 0.4277 0.0840 0.3190 0.0036 0.2610 0.1508 0.4511 0.0805
Mechanical prosthesis
82 (71.3 %)
10 (52.6 %)
5 (45.5 %)
0.0805
NYHA New York Heart Association, LVEF left ventricular ejection fraction * P
ORIGINAL ARTICLE
Long‑term results after treatment of the ascending aorta for bicuspid aortic valve patients Sho Matsuyama1 · Takahiro Nishida1 · Tomoki Ushijima1 · Ryuji Tominaga1
Received: 3 June 2015 / Accepted: 21 July 2015 © Springer Japan 2015
Abstract Purpose We evaluated the long-term results of aortic valve replacement for bicuspid aortic valve patients with or without surgical treatment of the ascending aorta. Methods A total of 145 bicuspid aortic valve patients had undergone aortic valve replacement since 1974 at our institution. No surgical treatment (Group-N; n = 115) was performed in the ascending aorta if the diameter was less than 40 mm. We wrapped an ascending aorta of 40–50 mm with an artificial graft (Group-W; n = 19), and performed replacement (Group-R; n = 11) if the ascending aorta measured more than 50 mm. Follow-up was completed for 144 patients (99.3 % of the cases). Results The hospital mortality rate was 1.4 %. There were no significant differences among Groups N, W and R in the freedom from valve-related death and cardiac death at 10 years after surgery. The rates of freedom from aortarelated events in the three groups at 10 years after surgery were 98.3 % (Group-N), 100 % (Group-W) and 100 % (Group-R). Conclusions The long-term survival was equivalent among the three groups, and the rates of freedom from aorta-related death or events were low. Our surgical protocol for the treatment of the enlarged ascending aorta associated with BAV is appropriate. Keywords Aortic operation · Bicuspid aortic valve · Aortic valve replacement · CHD in adults
Introduction A bicuspid aortic valve (BAV) is the most common congenital cardiac anomaly in adults, and affects 0.5–2.0 % of the population [1, 2]. Aortic stenosis (AS) and regurgitation (AR) are the most common complications of BAV, and bicuspid aortopathy, dilation of the ascending aorta, occurs in about one-half of BAV patients [2]. Reports have described several causes of bicuspid aortopathy, including hemodynamic derangements of the BAV [3, 4], histological abnormalities of the aortic media in BAV patients (including cystic medial necrosis and abnormal fibrillin-1) [5] and increased matrix metalloproteinase activity [6]. Ascending aortic events, including aortic dissection and aortic aneurysm rupture, generally cause catastrophic results. Therefore, it is important to prevent aortic events due to bicuspid aortopathy in BAV patients by improving the long-term results after aortic valve replacement (AVR). In general, the recent guidelines have recommended aortic replacement for BAV patients who have ascending aortic aneurysms greater than 45–50 mm in diameter [7]. However, the most appropriate criteria for aortic intervention for bicuspid aortopathy are still controversial. The purpose of this study was to analyze our 30-year clinical experience with aortic intervention for BAV patients in order to clarify the optimal management for bicuspid aortopathy.
Patients and methods * Takahiro Nishida [email protected]‑u.ac.jp 1
Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences, 3‑1‑1 Maidashi, Higashi‑ku, Fukuoka 812‑8582, Japan
All subjects enrolled in this research have given their informed consent, and this protocol has been approved by the institutional committee on human research. Between
13
Surg Today
November 25, 1974 and January 7, 2015, 145 patients with BAV underwent AVR with or without an ascending aortic procedure in our institute. A bioprosthesis was used in elderly patients [8, 9] and a mechanical prosthesis was used in younger patients. Our basic policy of surgery for a dilated ascending aorta with BAV is: we perform no intervention on the ascending aorta if the maximum diameter is less than 40 mm, wrapping of the ascending aorta if the maximum diameter is between 40 and 50 mm, and replacement of the ascending aorta if the maximum diameter is more than 50 mm. However, we decided on the surgical procedure both according to this protocol, as well as based on the patient’s age, frailty, complications, etc. As a result, 115 patients had no intervention on the ascending aorta (Group-N), and 19 and 11 patients underwent ascending aorta wrapping (Group-W) and ascending aorta replacement (Group-R), respectively. The main reason for AVR was aortic valve stenosis in 114 patients and aortic regurgitation in 31 patients. Although the durability of newer bioprostheses has been improving [8], mechanical prostheses (97 cases) were mainly used in this study because of the relatively younger age at operation. There were three patients with aortic annular enlargement. Table 1 shows the background and surgical data for the three groups. There were no significant differences among the three groups in terms of the gender, age, New York Heart Association functional class or preoperative left ventricular ejection fraction, although the preoperative maximum ascending aortic diameter was significantly different. The maximum ascending aortic diameter was larger in Group-R than in Groups-N and W. We measured the maximum ascending aortic diameter by a computed tomography (CT) scan, and also by aortogram, transesophageal echocardiography, or actual measurement during surgery if a preoperative CT scan was not available. The details of the operation and patient care were Table 1 Patient backgrounds and surgical data for the three groups
described previously [9, 10]. In brief, all patients underwent surgery with full sternotomy, standard cardiopulmonary bypass and moderate hypothermia (at 28–34 °C). Either cold crystalloid or blood cardioplegia was delivered antegrade, retrograde or both. Everting mattress sutures or horizontal mattress sutures with 2-0 braided polyester reinforced with polytetrafluoroethylene (Teflon) felt pledgets were predominantly used to suture the valves. Aortic wrapping using a vascular prosthesis was performed after AVR. The prosthesis was tailored and placed around the aorta from distal to the sinotubular junction to proximal to the innominate artery, and tightly wrapped with intermittent 3-0 polyester sutures. Circulatory arrest was not used during ascending aortic replacement, including during a Bentall procedure (two cases) and a Wheat procedure (one case). Early postoperative follow-up, followed by monthly or annual follow-up, was performed by us for most of the patients at our outpatient clinic. We directly contacted the patients themselves by interrupting visits, or through their family members or physicians, with questionnaires completed via mail or telephone. When the response to the questionnaire reported the patient’s death, we directly contacted the physician in charge in order to confirm the cause of death and/or related complications. One patient could not be contacted; thus, the follow-up was completed for 99.3 % of the patients, with a total of 1301.5 patient-years (Pt-Yrs). Hospital and late deaths, as well as all valve-related mortalities and complications, were strictly defined according to the published guidelines of the American Association for Thoracic Surgery/The Society of Thoracic Surgeons [11]. All continuous variables are presented as the mean ± standard error of the mean (SEM). Fisher’s exact test and Student’s t tests were used for the univariate analyses. The comparisons among the three groups for the
Group
Group-N
Group-W
Group-R
P value
Number Male (%) Age (years) NYHA Preoperative LVEF (%) Preoperative ascending aortic diameter (mm) Length of operation (min) Cardiopulmonary bypass time (min) Aorta cross-clamp time (min) Bioprosthesis
115 71 (61.7) 59.3 ± 1.5 2.13 ± 0.06 68.7 ± 1.5 37.1 ± 0.7* 349.9 ± 8.92 159.9 ± 5.52 107.3 ± 3.57 33 (28.7 %)
19 12 (70.6) 66.5 ± 2.8 2.00 ± 0.1 69.9 ± 1.7 47.8 ± 0.7 368.9 ± 18.18 164.6 ± 9.58 111.5 ± 7.59 9 (47.4 %)
11 7 (63.6) 53.4 ± 4.2 1.70 ± 0.1 62.3 ± 4.1 55.2 ± 1.6* 395.0 ± 34.1 174.1 ± 20.90 133.5 ± 14.1 6 (54.5 %)
0.7790 0.4277 0.0840 0.3190 0.0036 0.2610 0.1508 0.4511 0.0805
Mechanical prosthesis
82 (71.3 %)
10 (52.6 %)
5 (45.5 %)
0.0805
NYHA New York Heart Association, LVEF left ventricular ejection fraction * P
