title: Knowledge, attitudes, and practice patterns in surgical management of bicuspid aortopathy: a survey of 100 cardiac surgeons.
abstract: OBJECTIVE
  Clinical practice guidelines have been established for surgical management of the aorta in bicuspid aortic valve disease. We hypothesized that surgeons' knowledge of and attitudes toward bicuspid aortic valve aortopathy influence their surgical approaches.
  
  
  METHODS
  We surveyed cardiac surgeons to probe the knowledge of, attitudes toward, and surgical management of bicuspid aortopathy. A total of 100 Canadian adult cardiac surgeons participated.
  
  
  RESULTS
  Fifty-two percent of surgeons believed that the mechanism underlying aortic dilation in those with bicuspid aortic valve was due to an inherent genetic abnormality of the aorta, whereas only 2% believed that altered valve-related processes were involved in this process. Only a minority (15%) believed that bicuspid valve leaflet fusion type is associated with a unique pattern of aortic dilatation aortic phenotype. Sixty-five percent of surgeons recommended echocardiographic screening of first-degree relatives of patients with bicuspid aortic valve. Most surgeons (61%) elected to replace the aorta when the diameter is 45 mm or greater at the time of valve surgery. Fifty-five percent of surgeons surveyed suggested that in the absence of concomitant valvular disease, they would recommend ascending aortic replacement at a threshold of 50 mm or greater. Approximately one third of surgeons suggested that they would elect to replace a mildly dilated ascending aorta (40 mm) at the time of valve surgery. The most common surgical approach (61%) for combined valve and aortic surgery was aortic valve replacement and supracoronary replacement of the ascending aorta, and only a minority suggested the use of deep hypothermic circulatory arrest and open distal anastomosis. More aggressive approaches were favored with greater surgeon experience, and when circulatory arrest was chosen, the majority (68%) suggested they would use antegrade cerebral perfusion. In the setting of aortic insufficiency and a dilated aorta, 42% of surgeons suggested that they would perform valve-sparing surgery. Of note, 40% of respondents used an index measure of aortic size to body surface area in addition to absolute aortic diameter in assessing the threshold for intervention.
  
  
  CONCLUSIONS
  This large survey uncovered significant gaps in the knowledge and attitudes of surgeons toward the diagnosis and management of bicuspid aortopathy, many of which were at odds with current guideline recommendations. Efforts to promote knowledge translation in this area are strongly encouraged.
authors.affiliation: Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Subodh
authors.initials: S
authors.lastname: Verma
authors.forename: Bobby
authors.initials: B
authors.lastname: Yanagawa
authors.forename: Sameer
authors.initials: S
authors.lastname: Kalra
authors.forename: Marc
authors.initials: M
authors.lastname: Ruel
authors.forename: Mark D
authors.initials: MD
authors.lastname: Peterson
authors.forename: Michael H
authors.initials: MH
authors.lastname: Yamashita
authors.forename: Andrew
authors.initials: A
authors.lastname: Fagan
authors.forename: Maria E
authors.initials: ME
authors.lastname: Currie
authors.forename: Christopher W
authors.initials: CW
authors.lastname: White
authors.forename: Stephane Leung
authors.initials: SL
authors.lastname: Wai Sang
authors.forename: Cristian
authors.initials: C
authors.lastname: Rosu
authors.forename: Steve
authors.initials: S
authors.lastname: Singh
authors.forename: Holly
authors.initials: H
authors.lastname: Mewhort
authors.forename: Nandini
authors.initials: N
authors.lastname: Gupta
authors.forename: Paul W M
authors.initials: PW
authors.lastname: Fedak
mesh_terms: D000328:Adult; D001018:Aortic Diseases / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D001021:Aortic Valve / Q000002:abnormalities* / Q000601:surgery; D001291:Attitude of Health Personnel; D000082882:Bicuspid Aortic Valve Disease; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000592:standards; D002170:Canada; D002983:Clinical Competence / Q000592:standards; D004108:Dilatation, Pathologic; D019983:Guideline Adherence; D019538:Health Care Surveys; D007722:Health Knowledge, Attitudes, Practice; D006349:Heart Valve Diseases / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000592:standards; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards; D011237:Predictive Value of Tests; D012307:Risk Factors; D011795:Surveys and Questionnaires
keywords: 35; AHA; AVR; American Heart Association; BAV; aortic valve replacement; bicuspid aortic valve