Fate of Un-replaced Sinuses of Fate of Un-replaced Sinuses of Valsalva in Bicuspid Aortic Valve Valsalva in Bicuspid Aortic Valve

Disease: Follow-up to 17 yearsDisease: Follow-up to 17 years

Chan Park1, Hector Michelena2, Thoralf M. Sundt1

Divisions of Cardiovascular Surgery1 and Cardiovascular Medicine2

Mayo Clinic

Rochester, Minnesota

Patient CharacteristicsPatient Characteristics

Age (yrs)Age (yrs) 62±1362±13

Male (%)Male (%) 75.275.2

F/U period (yrs)F/U period (yrs) 0-17(3.3)0-17(3.3)

Diabetes mellitus (%)Diabetes mellitus (%) 10.110.1

Hypercholesterolemia (%)Hypercholesterolemia (%) 60.660.6

Renal failure (%)Renal failure (%) 2.32.3

NYHA III/IV (%)NYHA III/IV (%) 39.039.0

Coronary artery disease (%)Coronary artery disease (%) 30.730.7

Operative ResultsOperative Results

ACC (min)ACC (min) 68.8±28.968.8±28.9

CPB (min)CPB (min) 96.0±43.796.0±43.7

Circulatory arrest (min)Circulatory arrest (min) 18.5±13.218.5±13.2

Type of Valve (Mech:Bio)Type of Valve (Mech:Bio) 109:109109:109

ProceduresProcedures

NCC procedureNCC procedure 15 (6.9%)15 (6.9%)

Ascending aortoplastyAscending aortoplasty 65 (29.8%)65 (29.8%)

Ascending graftAscending graft 153 (70.2%)153 (70.2%)

Arch surgeryArch surgery 13 (6.0%)13 (6.0%)

Preoperative Echo findingPreoperative Echo finding

DominanceDominance

Stenosis (%)Stenosis (%) 69.669.6

Insufficiency (%)Insufficiency (%) 24.924.9

Mixed (%)Mixed (%) 5.55.5

EF (%)EF (%) 59.5±11.759.5±11.7

Size (mm)Size (mm)

AnnulusAnnulus 25.7±4.625.7±4.6

SinusSinus 40.4±5.740.4±5.7

STJSTJ 34.6±5.334.6±5.3

Ascending aortaAscending aorta 50.6±6.850.6±6.8

OutcomesOutcomes

• Operative mortality: 2.8%• Overall mortality: 28/218 (12.8%)• Cause of death

Cardiac 5/28 (17.9%)

Non-cardiac 11/28 (39.3%)

Unknown 12/28 (42.9%)

Reoperation

• Reoperation: 10/218 (4.6%)

• Indication

Aortic root dilation (1) Ascending aorta dilatation (2)

PVE (3)PVE (3)

PPM (2)PPM (2)

Others (4)Others (4)

Sex

Age

Interval (yrs)

Primary operation

Reason for reoperation Reoperation

M 49 13.2 Aortoplasty PPM AVR+CABG

M 71 0.3 AscAoRp PVE AVR

M 67 9.2Aortoplasty+CABG

Aortic Root and AscAo dilatation

Graft replaceof AoRoot & AscAo

M 65 1.5 Aortoplasty RCA aneurysm CABG

M 40 9.0 Aortoplasty PPM & AscAo dilatation AVR+AscAo replace

M 65 3.8 Aortoplasty PVEHomograft replacement of AoRoot & CABG

M 75 0.9 AscAoRp MediastinitisValveless Homograft AscAo replacement

M 75 0.3 AscAoRp PVEHomograft replacement of AoRoot

M 60 0.1TotalArch+ProxDesc+CABG

Thoracoabdominal aneurysm

Thoracoabdominal aorta replacement

M 63 1.3AscAoRp+PFO closure

Periprosthetic leakageRepair of periprosthetic leakage

Details for ReoperationsDetails for Reoperations

Survival Freedom from ReoperationSurvival Freedom from Reoperation

0

80

100

60

40

20

Pro

bab

ility

(%

)

0 2 4 6 8 10

Follow-up (years)

1 year probability: 97.6%

5 year probabilitiy: 94.9%

10 year probability: 85.5%

Univariate Analysis for Overall SurvivalUnivariate Analysis for Overall Survival

HRHR pp value value

AgeAge 1.081.08 0.0010.001

DMDM 4.994.99 <0.001<0.001

Preop renal failurePreop renal failure 6.866.86 0.0020.002

NYHA (III/IV)NYHA (III/IV) 2.412.41 0.0280.028

CADCAD 3.623.62 <0.001<0.001

Bioprosthetic valveBioprosthetic valve 2.472.47 0.0230.023

Multivariate Analysis for Overall SurvivalMultivariate Analysis for Overall Survival

HRHR pp value value

AgeAge 1.071.07 0.0010.001

DMDM 5.325.32 <0.001<0.001

Preop renal failurePreop renal failure 8.438.43 0.0010.001

NYHA (III/IV)NYHA (III/IV) 2.282.28 0.0440.044

Change of Aortic Size at 5 years Change of Aortic Size at 5 years (n= 28)(n= 28)

0

10

20

30

40

50 Preop Postop

Annulus Sinus STJ AscAo

Size (mm)

*

*†

* p<0.05 preop vs postop, † p<0.001 preop vs postop

Conclusions

• The sinuses of Valsalva rarely dilate The sinuses of Valsalva rarely dilate significantly after AVR and aortic repairsignificantly after AVR and aortic repair

• Separate valve and graft remains a Separate valve and graft remains a reasonable option in the absence of reasonable option in the absence of significant root dilatationsignificant root dilatation

• The ascending aorta remains at risk of late The ascending aorta remains at risk of late dilatation if treated with aortoplastydilatation if treated with aortoplasty