title: A shifting approach to management of the thoracic aorta in bicuspid aortic valve.
abstract: OBJECTIVE
  The scientific understanding of aortic dilation associated with bicuspid aortic valve (BAV) has evolved during the past 2 decades, along with improvements in diagnostic technology and surgical management. We aimed to evaluate secular trends and predictors of thoracic aortic surgery among patients with BAV in the United States.
  
  
  METHODS
  We used the 1998-2009 Nationwide Inpatient Sample, an administrative dataset representative of US hospital admissions, to identify hospitalizations for adults aged 18 years or more with BAV and aortic valve or thoracic aortic surgery. Covariates included age, gender, year, aortic dissection, endocarditis, thoracic aortic aneurysm, number of comorbidities, hospital teaching status and region, primary insurance, and concomitant coronary artery bypass surgery.
  
  
  RESULTS
  Between 1998 and 2009, 48,736 ± 3555 patients with BAV underwent aortic valve repair or replacement and 1679 ± 120 patients with BAV underwent isolated thoracic aortic surgery. The overall number of surgeries increased more than 3-fold, from 4556 ± 571 in 1998/1999 to 14,960 ± 2107 in 2008/2009 (P < .0001). The proportion of aortic valve repair or replacement including concomitant thoracic aortic surgery increased from 12.8% ± 1.4% in 1998/1999 to 28.5% ± 1.6% in 2008/2009, which mirrored an increasing proportion of patients with a diagnosis of thoracic aortic aneurysm. Mortality was equivalent for patients undergoing aortic valve repair or replacement with thoracic aortic surgery and those undergoing isolated aortic valve repair or replacement (1.8% ± 0.3% vs 1.5% ± 0.2%; multivariable odds ratio, 1.02; 95% confidence interval, 0.67-1.57), with decreasing mortality over the study period (from 2.5% ± 0.6% in 1998/1999 to 1.5% ± 0.2% in 2008/2009; multivariable odds ratio per 2-year increment, 0.89; 95% confidence interval, 0.81-0.99; P = .03). Total charges for BAV surgical hospitalizations increased more than 7.5-fold from approximately $156 million in 1998 to $1.2 billion in 2009 (inflation-adjusted 2009 dollars).
  
  
  CONCLUSIONS
  There was a marked increase in the use of thoracic aortic surgery among patients with BAV.
authors.affiliation: Department of Cardiology, Boston Children's Hospital, Boston, Mass 02115, USA. alexander.opotowsky@childrens.harvard.edu
authors.forename: Alexander R
authors.initials: AR
authors.lastname: Opotowsky
authors.forename: Todd
authors.initials: T
authors.lastname: Perlstein
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Landzberg
authors.forename: Steven D
authors.initials: SD
authors.lastname: Colan
authors.forename: Patrick T
authors.initials: PT
authors.lastname: O'Gara
authors.forename: Simon C
authors.initials: SC
authors.lastname: Body
authors.forename: Liam F
authors.initials: LF
authors.lastname: Ryan
authors.forename: Sary
authors.initials: S
authors.lastname: Aranki
authors.forename: Michael N
authors.initials: MN
authors.lastname: Singh
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000191:economics / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D001021:Aortic Valve / Q000002:abnormalities / Q000601:surgery; D000082882:Bicuspid Aortic Valve Disease; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000191:economics / Q000401:mortality / Q000639:trends*; D019992:Databases as Topic; D004108:Dilatation, Pathologic; D005260:Female; D006349:Heart Valve Diseases / Q000150:complications / Q000191:economics / Q000401:mortality / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000639:trends; D017721:Hospital Costs / Q000639:trends; D006801:Humans; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000639:trends*; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics / Q000401:mortality / Q000639:trends*; D055815:Young Adult
keywords: 20.2; 26.1; ACC; AHA; AVR; American College of Cardiology; American Heart Association; BAV; CI; OR; TAA; TAS; aortic valve repair or replacement; bicuspid aortic valve; confidence interval; odds ratio; thoracic aortic aneurysm; thoracic aortic surgery