title: Long-term durability of bicuspid aortic valve repair.
abstract: BACKGROUND
  Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation, occurring in 1% to 2% of the population. Eventually, 20% develop clinically important valvar regurgitation requiring surgical intervention. Aortic valve repair avoids anticoagulation and prosthetic valve-related complications. This study evaluated long-term durability of BAV repair.
  
  
  METHODS
  From 1985 to 2011, 728 patients, mean age 42±12 years, underwent BAV repair at Cleveland Clinic. Mean follow-up was 9.0±6.2 years (median, 8.3). Factors associated with repair durability (expressed as aortic valve reoperations and echocardiographically estimated gradients and regurgitation) and survival were identified.
  
  
  RESULTS
  Hospital mortality was 0.41% (n=3), and stroke occurred in 0.27% (n=2). Freedom from aortic valve reoperation at 10 years was 78%. Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years. Primary reasons for reoperation were cusp prolapse (38%), aortic stenosis or regurgitation (17%), and aortic regurgitation from root aneurysm (15%). Aortic valve gradients showed an early initial peak, rapidly declined, then rose steadily, accompanied by an increase in left ventricular mass. Survival was 94% at 10 years. A risk factor for early death was greater preoperative mitral valve regurgitation, and for late death, older age at operation, more severe symptoms, and poorer left ventricular function.
  
  
  CONCLUSIONS
  BAV repair is safe and durable with low mortality, low prevalence of reoperation, and good long-term survival. Cusp prolapse from technical errors and natural progression of disease are the most common causes for reoperation, but progressive natural increase in valve gradient accounts for a substantial proportion as well.
authors.affiliation: The Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: svenssl@ccf.org.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: The Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Al Kindi
authors.affiliation: The Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Vivacqua
authors.affiliation: The Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Gösta B
authors.initials: GB
authors.lastname: Pettersson
authors.affiliation: The Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
authors.affiliation: The Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Tomislav
authors.initials: T
authors.lastname: Mihaljevic
authors.affiliation: The Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.affiliation: The Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.affiliation: The Aortic Center, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Brian
authors.initials: B
authors.lastname: Griffin
authors.affiliation: The Aortic Center, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Donald F
authors.initials: DF
authors.lastname: Hammer
authors.affiliation: The Aortic Center, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Leonardo
authors.initials: L
authors.lastname: Rodriguez
authors.affiliation: Department of Quantitative Health Sciences, Cleveland Clinic, Research Institute, Cleveland, Ohio.
authors.forename: Sarah J
authors.initials: SJ
authors.lastname: Williams
authors.affiliation: The Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Research Institute, Cleveland, Ohio.
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
authors.affiliation: The Aortic Center, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Bruce W
authors.initials: BW
authors.lastname: Lytle
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D001021:Aortic Valve / Q000002:abnormalities* / Q000000981:diagnostic imaging / Q000601:surgery; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D000082882:Bicuspid Aortic Valve Disease; D015331:Cohort Studies; D015150:Echocardiography, Doppler; D005260:Female; D005500:Follow-Up Studies; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging / Q000601:surgery*; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009820:Ohio; D011475:Prosthesis Failure; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome