Toward individualized management of the ascending aorta in bicuspid aortic valve surgery: the role of valve phenotype in 1362 patients.
OBJECTIVE
Decision making regarding the management of the ascending aorta (AA) in patients with a bicuspid aortic valve (BAV) undergoing valve surgery has hardly been individualized and remains controversial. We analyzed our individualized, multifactorial approach, focusing on the BAV phenotype.


METHODS
In 1362 patients (1044 men) undergoing aortic valve surgery, the BAV phenotypes were intraoperatively classified and retrospectively analyzed. The mean follow-up was 5.4±3.6 years (range, 0-14; 7334 patient-years), and the data were 96.5% complete. The individualized AA management decision process mainly included the AA diameter, age, body surface area, macroscopic AA configuration, and the perceived tissue strength of the aortic wall resulting in 3 AA treatment groups: no intervention, aortoplasty (AoP), and AA replacement (AAR).


RESULTS
In 906 patients (66.5%), no intervention was performed and 172 (12.6%) and 284 (20.9%) underwent AoP and AAR, respectively. The hospital mortality was 1.1% for no intervention, 0.6% for AoP, and 0.4% for AAR (P=.4). The 10-year survival was similar for all 3 groups and comparable to that of the general population. Five reoperations on the AA occurred, 4 in the no intervention and 1 in the AoP group. BAV type 2/unicuspid patients were younger and more had undergone AAR in absolute numbers and after allowing for the AA diameter. Also, in patients with BAV type 1 LR and regurgitation, AAR was performed more often.


CONCLUSIONS
The individualized, multifactorial management of AA in patients with BAV during aortic valve surgery leads to excellent results. The threshold AA diameter for intervention (AoP or AAR) varied from 34 to 51 mm (mean, 43.9). BAV type 2/unicuspid and BAV type 1 LR with regurgitation emerged as determinants for more liberal AAR in our practice. Longer term follow-up is necessary to confirm our conclusions.
Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany. Electronic address: Hans-Hinrich.Sievers@uksh.de.
Hans-Hinrich
HH
Sievers
Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany.
Ulrich
U
Stierle
Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany.
Salah A
SA
Mohamed
Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany.
Thorsten
T
Hanke
Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany.
Doreen
D
Richardt
Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany.
Claudia
C
Schmidtke
Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany.
Efstratios I
EI
Charitos
D000328:Adult; D000368:Aged; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D001021:Aortic Valve / Q000002:abnormalities* / Q000601:surgery; D000082882:Bicuspid Aortic Valve Disease; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D003661:Decision Support Techniques; D005260:Female; D006349:Heart Valve Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D010641:Phenotype; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D057285:Precision Medicine; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome