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Ann Thorac Surg 2007;83:931-937
© 2007 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Risk Factors Associated With Reoperation and Mortality in 252 Patients After Aortic Valve Replacement for Congenitally Bicuspid Aortic Valve Disease

Sorel Goland, MDa, Lawrence S.C. Czer, MDa,*, Michele A. De Robertis, RNb, James Mirocha, MSb, Robert M. Kass, MDb, Gregory P. Fontana, MDb, Wen Chang, MDb, Alfredo Trento, MDb

a Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
b Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California

Accepted for publication October 16, 2006.

* Address correspondence to Dr Czer, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Room 6215, Los Angeles, CA 90048 (Email: lawrence.czer{at}cshs.org).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: We aimed to determine the risk factors associated with mortality in patients with congenitally bicuspid aortic valve disease and dilation (<5 cm) of the ascending aorta after aortic valve replacement.

Methods: We reviewed 252 patients with bicuspid aortic valve undergoing aortic valve replacement at our institution from 1971 through 2000. Patients undergoing concomitant replacement of the ascending aorta were excluded.

Results: The average patient age was 61 ± 15 years; 66.3% were male, and 40.5% of patients had coronary artery disease. The ascending aorta was normal (<4.0 cm) in 60.3%, mildly dilated (4.0 to 4.4 cm) in 24.2%, and moderately dilated (4.5 to 4.9 cm) in 15.5% of patients. Patients with moderate aortic dilatation had significantly lower prevalence of coronary artery disease compared with patients with normal ascending aortas (20.5% and 45.4%; p = 0.006). Mean follow-up was 8.9 ± 6.3 years. Long-term survival was significantly different across the three groups (p = 0.004). The 5-, 10-, and 15-year estimates were 78%, 59%, and 37%, respectively, in the normal aorta group; 88%, 77%, and 46%, respectively, in the mild aortic dilation group; and 92%, 83%, and 70%, respectively, in the moderate aortic dilation group. No significant difference in cardiac death was found among the groups (p = 0.08). The significant predictors of survival using the Cox regression model were coronary artery disease, age, decade of surgery, and ejection fraction. Aortic dilation was not significant after adjusting for these other variables. At follow-up, 18 patients required reoperation, 17 for aortic valve prosthesis failure and 1 for ascending aorta aneurysm.

Conclusions: The present study highlights the important adverse effect of concomitant coronary artery disease, advanced age, earlier decade of surgery, and reduced left ventricular ejection fraction on survival after aortic valve replacement for bicuspid aortic valve in patients with no or mild and moderate (<5 cm) dilation of the ascending aorta.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation [1, 2] and may be a benign condition often undetected throughout life. However, there is a high incidence of premature serious aortic valve disease presenting as aortic stenosis and regurgitation or endocarditis [1, 3, 4]. Underlying disease of the ascending aorta may accompany BAV and can lead to serious clinical consequences such as aortic dilation, dissection, or rupture [5–9]. Previous studies described dilation of the aorta in patients with hemodynamically significant BAV lesions or with other well-known risk factors such as hypertension, smoking, or aortic coarctation [1, 5, 10–12].

Echocardiographic studies have identified an independent link between BAV and aortic dilation [7–9, 13–14]. Recently, dilated aortic roots and ascending aortas (AA) were observed in patients with a bicuspid but functionally normal aortic valve [15]. This finding was supported by a number of histologic studies that demonstrated an intrinsic defect in the connective tissue of the aortic wall in patients with BAV [16–18].

Aortic valve replacement (AVR) is standard treatment for symptomatic aortic valve disease. A relatively high incidence of accompanying AA dilation is present in patients with BAV when AVR is required [19, 20]. The current indication for elective replacement of the AA for degenerative aneurysms is a diameter exceeding 5.5 cm or 5.0 cm for Marfan’s syndrome and cystic medial disease [21]. Concomitant repair or replacement of the AA at the time of initial AVR surgery is controversial. A few studies have suggested prophylactic replacement of the AA at a smaller diameter than recommended because of the higher risk of aorta-related complications in patients with BAV [19, 20].

The influence of other risk factors such as concomitant coronary artery disease (CAD) on the outcome after AVR in this patient population has not been investigated. The reported incidence of coexistent CAD is lower in patients with stenotic BAV than in tricuspid aortic valves, but is still obtained in more than a third of patients who required aortic valve surgery [20, 22]. Thus, there is limited information regarding the clinical outcomes and incidence of aortic complications in patients with a dilated AA and AVR in patients with BVD. The aim of the present study was to determine the risk factors associated with mortality and the incidence of aortic complications in this patient population.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patients
From February 1971 through March 2002, all patients who underwent AVR surgery for congenital BAV were identified through our division’s computerized database for inclusion in the study if they did not undergo concomitant AA repair or replacement or other valve replacement surgery. This study was approved by the Institutional Review Board at Cedars-Sinai Medical Center with a waiver to obtain consent based on the retrospective study nature and removal of identification of patient data. All patients are prospectively entered into an Institutional Review Board–certified quality assurance database. After surgery, patients have been followed for the duration of their life by mailed questionnaires, telephone interview, or examination in our offices.

Surgical Procedures
Surgery was performed on all patients predominantly by 5 surgeons who make up the Division of Cardiothoracic Surgery at Cedars-Sinai Medical Center. Indications for surgery of the AA and AVR have remained consistent during the study period.

The aortic valve was determined as bicuspid by the surgeon and on the basis of previously published criteria [4]. The AA was assessed preoperatively by noninvasive imaging either with magnetic resonance imaging, computed tomographic scan, or transesophageal echocardiography. Intraoperatively, direct measurements were obtained using a millimeter ruler or transesophageal echocardiogram. Operative and diagnostic reports for all patients were reviewed to determine the size of the AA at the time of surgery. The maximal AA diameter was obtained directly by a surgeon and measured above the sinotubular junction by transesophageal echocardiography. Descriptions of the AA was reported as normal when the diameter was less than 4 cm, mild dilation for a diameter of 4.0 to 4.4 cm, and moderate dilation for a diameter of 4.5 to 4.9 cm. The aorta was classified as normal in 73 (30%) patients when there was no statement of an abnormality in the preoperative catheterization, noninvasive assessment, or operative reports. Patients with AA dilation of 5 cm or greater had aortic replacement and therefore were excluded from this analysis.

Aortic valve replacement was performed by the standard technique [23] using either prosthetic or tissue valves. Stentless valves were not used in this patient population. Patients with a small aortic annulus (19 mm) and high body surface area and aortic valve area/BSA <0.7 underwent aortic annulus enlargement using the Nicks procedure. The Ross procedure was performed using the standard technique; with an aortic annuloplasty in patients with a dilated annulus to prevent further dilatation. The annulus was reduced to 26 mm in diameter. All patients underwent cardiopulmonary bypass with mild-to-moderate systemic hypothermia. Antegrade crystalloid cardioplegia was used before 1989, and antegrade blood cardioplegia has been used since. Coronary artery bypass graft surgery was performed with antegrade and retrograde cardioplegia in patients with concomitant CAD (≥70% stenosis). Presence of CAD was defined by 50% or greater stenosis of any coronary artery.

Statistical Analysis
Continuous variables were summarized as mean ± standard deviation. Group comparisons of continuous variables were performed with analysis of variance or the Kruskal–Wallis test, as appropriate. Categorical variables were summarized as percent or as count (percent). Group comparisons of categorical variables were performed using the {chi}2 or Fisher’s exact test, as appropriate. Survival estimates were generated by the Kaplan–Meier method. The log-rank test was used to compare survival across groups. Multivariable stepwise Cox proportional hazards models were used to assess variables associated with the risk of death; results were summarized with hazard ratios and 95% confidence intervals. All statistical tests were two-sided, and a significance level of 0.05 was used throughout. Statistical analyses were performed using the SAS system, version 9.1 (SAS Institute Inc, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
A total of 252 patients with BAV underwent AVR without concomitant replacement of AA. The mean follow-up was 8.9 ± 6.3 years (range, 0–31.0 years). Of the 252 patients, 50.4% had aortic stenosis, 12.4% had aortic regurgitation, and 37.2% mixed lesions.

All patients underwent AVR; no aortic valve repair was done. A tissue valve was used in 35.3% of patients, a mechanical valve in 54.4% of patients, and a pulmonary allograft was placed in 10.3% of patients. Concomitant coronary artery bypass graft surgery was performed in 33.7% and mitral valve repair in 2.8%. The overall mean cross-clamp time was 100.9 ± 33.7 minutes, and the mean perfusion time was 139.4 ± 43.6 minutes. The mean cross-clamp time for isolated AVR was 76.8 ± 28.8 minutes, and the mean perfusion time was 115.8 ± 31.2 minutes; for AVR plus coronary artery bypass graft surgery, 117.0 ± 36.6 minutes and 166.2 ± 43.8 minutes, respectively; for Ross operation, 124.2 ± 20.4 minutes and 159.6 ± 24.0 minutes; and for AVR plus other concomitant procedures, 166.2 ± 30.6 minutes and 187.8 ± 36.0 minutes, respectively (p < 0.0001).

Among all 252 patients with BAV who underwent AVR, 152 (60%) presented with a normal AA (<4 cm), 61 (24.2%) patients had mild dilation of AA (4.0 to 4.4 cm), and 39 (15.5%) patients had moderate AA dilation (4.5 to 4.9 cm). Patient demographics and preoperative characteristics of the entire group and by degree of AA dilation are demonstrated in Table 1. No significant differences were observed among groups regarding age, body surface area, sex, hypertension, diabetes mellitus, New York Heart Association functional class, or left ventricular ejection fraction. Patients with moderate AA dilation had significantly lower prevalence of CAD. No difference in the distribution of aortic valve lesion was observed among the three groups. The intraoperative characteristics including concomitant mitral valve repair and aortic cross-clamp and perfusion times were similar in all groups, with the exception of prevalence of concomitant coronary artery bypass graft surgery, which was significantly lower in the moderate AA dilation group (38.2%, 34.4%, and 15.4%, respectively; p = 0.02). Similar distribution of tissue, mechanical, and pulmonary allografts was observed in patients with normal AA and with mild and moderate AA dilation (p = 0.2). Prosthetic valve size distribution between normal AA and mild and moderate AA dilation was compared. Prosthetic valves size 19 to 21 mm were used in 28% of patients in the normal AA group, and 19% and 16% in mild and moderate AA dilation groups, respectively; sizes 23 to 25 mm were used in 58% of patients in normal AA group, and 57% and 52% in mild and moderate AA dilation groups, respectively; sizes 27 to 29 mm were utilized in 14% of patients in normal AA group, and 24% and 32% in mild and moderate AA dilation groups, respectively. In both the mild and moderate AA dilation subgroups larger sizes of prosthetic valve were used compared with the group having a normal AA (p = 0.03 among three groups). Patient prosthesis mismatch (effective orifice area index, <0.85) was found in 19% of patients, with no significant difference between patients with any dilatation of aorta and normal AA (14% versus 23%; p = 0.39).


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  		Table 1 Demographics and Preoperative Patient Characteristics of All 252 Patients Undergoing Aortic Valve Replacement for Bicuspid Aortic Valve Disease and Divided Into Three Groups by Degree of Ascending Aorta Dilatation
 
The 30-day mortality of the entire group was 2.4%, the in-hospital mortality was 1.5%. Three patients (1.2%) had stroke, and 17 patients (6.5%) had myocardial infarction within the first month after surgery.

Follow-up was obtained on 99% of patients. The 5-, 10-, and 15-year survivals were 83%, 67%, and 47%, respectively. A total of 103 (41%) patients died during long-term follow-up. Fifty patients (20%) died of cardiac death. The causes of death are shown in Table 2.


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  		Table 2 All Cause and Cardiac Death During Long-Term Follow-Up in 252 Patients Undergoing Aortic Valve Replacement for Bicuspid Aortic Valve Disease Divided in Three Groups by Degree of Ascending Aorta Dilatation a b
 
Long-term survival was significantly different across the three groups (p = 0.004). The 5-, 10-, and 15-year estimates were 78%, 59%, and 37%, respectively, in the normal aorta group, 88%, 77%, and 46%, respectively, in the mild AA dilation group, and 92%, 83%, and 70%, respectively, in the moderate AA dilation groups. Kaplan–Meier survival curves for these three groups are shown in Figure 1. Significant differences in survival for the entire group were obtained by decade of surgery (Fig 2) and preoperative presence of CAD (Fig 3).


Figure 1
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  		Fig 1. Survival of 252 patients undergoing aortic valve replacement for bicuspid aortic valve disease by degree of ascending aorta (AA) dilatation. Summary table provides survival estimates (± standard deviation) at 5, 10, and 15 years, respectively.

 

Figure 2
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  		Fig 2. Survival by decade of aortic valve replacement of 252 patients with bicuspid aortic valve disease. Summary table provides survival estimates (± standard deviation) at 5, 10, and 15 years, respectively.

 

Figure 3
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  		Fig 3. Survival of 252 patients undergoing aortic valve replacement for bicuspid aortic valve disease by presence or absence of coronary artery disease (CAD). Summary table provides survival estimates (± standard deviation) at 5, 10, and 15 years, respectively.

 
The distribution of all-cause and cardiac death among the three groups is presented in Table 2. Patients with normal AA had a higher incidence of all-cause death than the patients with AA dilation (72.8% versus 15.5% versus 11.7%). In 1 patient with mild and 2 patients with moderate dilation of the aorta, the cause of death was unknown. However, taking into account the possibility of any aortic complication, we included these patients in the cardiac death group. Thus, cardiac deaths occurred in 10 of 28 (35.7%) patients with any aortic dilatation and in 43 of 75 (57.3%) patients with normal AA (p = 0.08).

At follow-up, 18 patients (7.1%) required reoperation, 17 (95%) for aortic valve prosthesis failure and 1 (5%) patient for AA aneurysm. The causes of reoperation are presented in Table 3. Valve-related cause of reoperation occurred in 5 of 6 patients (83%) with dilated AA and 12 of 12 patients (100%) with normal AA (p = 0.33).


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  		Table 3 Causes of Reoperation During Long-Term Follow-Up in the Entire Group of 252 Patients Undergoing Aortic Valve Replacement for Bicuspid Aortic Valve Disease and Divided Into Three Groups by Degree of Ascending Aorta Dilatation a
 
Age, ejection fraction, CAD, decade of surgery, degree of aortic dilation, diabetes, and hypertension were used in the stepwise Cox regression model. The significant predictors of survival using the Cox regression model were CAD, age, decade of surgery, and left ventricular ejection fraction (Table 4). Aortic dilation (<5 cm) was no longer significant after these variables were included.


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  		Table 4 Predictors of Survival in 252 Patients Undergoing Aortic Valve Replacement for Bicuspid Aortic Valve Disease Using the Cox Regression Model
 
Twenty-six patients underwent the Ross procedure. Ross patients were significantly younger than the rest of the cohort (46 ± 10 versus 62 ± 14 years; p < 0.0001). There was somewhat lower rate of the Ross procedure in the normal aorta group, compared with mildly and moderately dilated aorta groups (8%, 12%, and 15%; p = 0.2). However, when this variable was included in the Cox model, the Ross procedure by itself was not significantly related to the risk of death.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Bicuspid aortic valve disease is a common congenital cardiac disorder affecting 1% to 2% of the general population with an autosomal dominant inheritance pattern [1, 2, 24]. Large autopsy studies described aortic stenosis as the predominant lesion in a population with BAV with a lower incidence (10% to 15%) of aortic insufficiency and mixed lesions [4]. In the present study of 252 patients with BAV, we found that half of the patients had pure aortic stenosis and 37% had mixed lesions. The age and prevalence of hypertension was the same as reported by others [20, 25]. However, a higher prevalence of CAD was observed in our study. With a mean age of 61 years, 40% of the patients in this study presented with CAD.

Bicuspid aortic valve is often associated with other cardiovascular abnormalities such as aortic dilation, aneurysm formation, and aortic coarctation [5–9]. All these disorders can lead to serious clinical consequences such as aortic dissection and rupture. The hemodynamic effect of aortic stenosis and regurgitation in BAV patients had been thought to be the main cause of progressive aortic dilation. However, a recent report of pure, severe aortic stenosis showed that BAV patients commonly had larger AA compared with those who had tricuspid valves [25]. The presence of BAV in patients with fatal aortic complications raised the possibility that BAV itself can be a risk factor for aortic wall abnormalities independent of the severity of valvular dysfunction, hypertension, or coarctation [26, 27]. This hypothesis has been supported by imaging and histologic studies that show an independent association between BAV and aortic dilation regardless of hemodynamic abnormalities, age, and body size in these patients [7–9, 13, 14].

Recently, Nkomo and associates [15] published an epidemiologic echocardiographic study including 16 patients with BAV without hemodynamically significant stenosis or regurgitation. These patients had a larger aortic annulus, aortic sinus, and proximal AA compared with control patients with normal tricuspid aortic valves. The two groups were matched with respect to age, sex, and body surface area. These findings suggest the hypothesis of an association between BAV and aortic dilation.

The reason for aortic abnormalities in patients with BAV is still a matter of investigation. Intrinsic aortic wall abnormalities appear to be similar to cystic medial necrosis [28]. This underlying condition of the aorta with contribution of blood flow turbulence can lead to vascular endothelial cell apoptosis and consequently cause aneurysm formation and dissection [29]. A growing amount of evidence suggests that reduced extracellular matrix component (fibrillin 1) and an increase of degradation enzyme (metalloproteinase 2) activity are important mechanisms of the aortic media disease in BAV patients [17].

There is a paucity of data regarding long-term outcomes of patients with BAV who underwent aortic valve surgery. One of the known factors that can affect the long-term survival after AVR in this population is AA complications. Dilation of the AA in BAV patients who are referred for AVR raises an important surgical decision regarding concomitant AA surgery. In the present study, all patients were divided into three groups (normal and mild and moderate AA dilation) on the basis of the size of the AA at the time of AVR. Forty percent of the patients included in this study with BAV and who underwent AVR had mild or moderate dilatation of AA. All three groups of patients were similar in several preoperative characteristics including age, sex, and hypertension. However, patients with moderate AA dilation had less CAD and consequently had less concomitant coronary artery bypass graft surgery.

In our study, we found no difference in survival between patients with normal aortas versus patients with mildly dilated (4.0 to 4.4 cm) or moderately dilated (4.5 to 4.9 cm) aortas after adjusting for CAD, age, decade of surgery, and ejection fraction in a multivariate Cox analysis. Importantly, patients with an enlarged aorta and concomitant CAD had worse survival compared with those with no CAD. Previously reported prevalence of CAD in patients with congenital aortic stenosis having AVR has been lower than in patients with tricuspid aortic valves (39% versus 53%) [30, 31]; in our study, the prevalence of CAD was 40%. Combined cardiac procedures such as AVR and coronary artery bypass graft surgery carry an increase in perioperative mortality in patients with aortic valve disease [32]. The impact of the accompanying CAD on the outcomes after AVR in patients with BAV has not been previously investigated. The identification of CAD as the powerful predictor of mortality in patients with BAV having AVR has important clinical implications.

Coronary artery disease was followed by older age, earlier decade of surgery, and impaired left ventricular function as additional risk factors for poor outcome in this patient population. Aortic disease entered but was no longer significant after CAD, age, decade of surgery, and left ventricular ejection fraction were included in the Cox survival model. This implies that studies of AA dilation less than 5 cm must take into account the significant effect of concomitant CAD, advanced age, earlier decade of surgery, and reduced left ventricular ejection fraction on survival after AVR for BAV. The significant effect of CAD on survival after AVR for BAV has not been previously appreciated.

In contrast to the present report, several previous studies with long-term follow-up of patients with BAV and dilation of AA initially at the time of AVR had found significant differences in survival and rate of aortic complications [19, 20, 33]. Russo and coworkers [19] reported that 10% of patients experienced acute aortic dissection and sudden death, and 6% required surgery for significant aortic dilation among 50 patients with BAV [19]. These authors recommended a prophylactic replacement of even a seemingly normal or mildly dilated AA at the time of AVR in this population of patients. Borger and colleagues [20] recently followed 201 patients with BAV after AVR for a mean of 10.3 years and showed that 15-year survival in the group with moderate dilatation of the aorta was significant lower (43%) compared with 81% in the mildly dilated AA group and 83% in patients with a normal aorta. Two other studies with a smaller number of patients and shorter follow-up have been published recently. Kuralay and associates [34] compared patients with BAV who underwent AVR only with those who had concomitant aortic replacement (Dacron wrapping was performed in all patients). The AA diameter increment was found to be 1.25 mm/year in normotensive and 2.80 mm/year in hypertensive patients. This finding supports the important role of hypertension in AA dilation in this population after AVR. Andrus and colleagues [35] studied 185 patients undergoing AVR through a mean follow-up of 30 months and found progressive AA dilatation in 15% of the entire population and 9.3% in the population with baseline enlarged AA. When analyzing the group of expanders, no clinical or valvular predictors were found to be associated with AA dilatation; however, there was a trend toward more rapid expansion in patients with congenital aortic stenosis [35].

In the current study we did not find an increased rate of aortic complications in patients with mild and moderate AA dilatation. It can partially be explained by the fact that this particular patient population was well treated regarding risk factors for AA dilatation including hypertension (76% were treated with ß-blockers, 59% with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers). However, in our retrospective study, in 2 patients with moderate dilatation of the aorta, the cause of death was unknown, so the rate of the aortic complication may be underestimated.

The surgical approach for patients with mild and moderate dilation of AA (<5 cm) is still controversial. Previous studies to determine the progression of aortic dilation and aortic complications after AVR in BAV patients have not taken into account the treatment of hypertension, especially ß-blocker therapy. The ability of ß-adrenergic blockade to promote the elastic properties of the aorta and retard the aortic dilatation has been previously described in those with Marfan’s syndrome. Moreover, survival improvement has been demonstrated in patients with Marfan’s syndrome treated with ß-blockers [36, 37]. Therefore, prospective randomized studies are required to evaluate the influence of early postoperative therapy such as ß-blockers on rate of progression of AA dilatation and to determine the optimal size for AA replacement during aortic valve surgery in patients with BAV. The surgical treatment of patients with a BAV needs to be individualized and risk factors need to be accounted for in the decision-making process.

Study Limitations
The main limitation of our study is its retrospective design. Moreover, it was not randomized regarding replacement of the AA. In 73 patients, the AA was classified as normal when there was no description of an abnormality in the preoperative catheterization, noninvasive evaluation, or operative reports. Another limitation of the study was the number of patients (2 of 12, 16.7%) in whom the cause of death was unknown in the group with moderately dilated AA, so the aortic complication rate may be underestimated. Therefore, this particular study cannot be used to give the definitive answer regarding the optimal diameter for AA replacement during aortic valve surgery in patients with BAV and mild or moderate dilation of the AA.

Conclusions
The present study highlights the important adverse effects of concomitant CAD, advanced age, earlier decade of surgery, and reduced left ventricular ejection fraction on survival after AVR for BAV in patients with no or mild and moderate (<5 cm) dilation of the AA.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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