Original article
Adult cardiac
Aortic Valve Morphology Determines the Presentation and Surgical Approach to Acute Type A Aortic Dissection

Presented at the Fiftieth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 25–29, 2014.
https://doi.org/10.1016/j.athoracsur.2013.12.090Get rights and content

Background

Data on acute type A aortic dissection in patients with bicuspid aortic valve (BAV) syndrome are limited. This investigation evaluated the clinical details in patients with type A dissection stratified according to aortic valve morphology.

Methods

Between 1993 and 2013, 629 patients (median age 61 years [50; 73], 64% men) underwent surgical procedures for type A dissection. Forty-one patients with BAV were compared with 588 patients with tricuspid aortic valve (TAV).

Results

The BAV patients were younger (55 years [46; 67] vs 61 years [51; 73] years; p < 0.001), presented more frequently with moderate or severe aortic insufficiency (51% vs 34%; p = 0.039), cardiogenic shock (37 vs 21%; p = 0.029), and had larger ascending aorta diameters (5.5 cm [5.1; 6.4] vs 4.8 cm [4.4; 5.5] cm; p < 0.001). The BAV patients more frequently required aortic root replacement (81% vs 14%; p < 0.001). Total arch replacement was performed in 5% of the BAV patients and 4% of the TAV patients. In-hospital mortality (14.6% vs 13.1%; p = 1.0) and survival at 5, 10, and 15 years (56% ± 8%, 46% ± 10%, and 37% ± 11% vs 68% ± 2%, 49% ± 3%, and 36% ± 4%; log rank, p = 0.4) were similar in the BAV and TAV patients. Twenty (3%) TAV and no BAV patients underwent proximal reoperations (p = 0.6) at a median follow-up time of 4.1 years (range, 0.8 to 6.9 years).

Conclusions

BAV patients experience dissection at a younger age and at a greater ascending aortic diameter. Extensive aortic root repair in BAV patients is not associated with higher in-hospital mortality and prevents the need for later proximal redo operation.

Section snippets

Study Population

Between 1993 and 2013, among 629 patients (age 61 years [range, 60 to 73 years], 64% men) operated on for acute Stanford type A aortic dissection, 41 patients (7%) had BAV. The diagnosis of BAV was confirmed at operation. Acute aortic dissection was defined as a dissection operated on no later than 14 days after the onset of symptoms. Ascending aortic diameter was assessed before operation by transesophageal echocardiography and was available in 482 patients (77%).

The institutional review

Clinical Presentation

Patients with BAV were an average of 6 years younger (55 [46; 67] vs 61 [51; 73] years; p = 0.030) (Fig 1) and were in a similar gender distribution (63% vs 64% males; p = 0.9) as TAV patients. The BAV patients had a lower incidence of hypertension (56% vs 81%; p < 0.001). The incidence of all other cardiovascular risk factors did not differ between the two groups (Table 1). Three BAV patients underwent aortic valve replacement 23, 8, and 4 years before type A dissection. Two BAV patients

Patients With BAV Experience Dissection at a Younger Age

Aortic dissection can occur at any age; however, the highest incidence of type A dissection is during the seventh and eighth decades [16]. The International Registry for Acute Aortic dissection investigators suggested that younger patients (<40 years old) who experienced type A or B aortic dissection more often had a BAV than did older patients (>40 years old; 9% vs 1%; p < 0.01) [17]. In a recent report from Shanghai on a relatively young type A dissection population including 30 BAV and 258

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