Date of Award

1-1-2020

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

John A. Elefteriades

Abstract

Hypothesis: Thoracic aortic aneurysm (TAA) is a silent but virulent disease. Bicuspid aortic valve (BAV) is the most common congenital heart disease. The association between BAV and ascending TAA (ATAA) is well described. However, the guidelines for surgical management to treat patients with thoracic aortic aneurysms associated with bicuspid aortic valve (ATAA-BAV) remains controversial. We hypothesized that the surgical management of patients with ATAA-BAV should not differ from the management of those who have ATAA with a trileaflet aortic valve (TAV). Additionally, we suspected that BAVs that are free of stenosis and regurgitation can be spared in the setting of ATAA repair. In this study, we aimed to (1) characterize the natural behavior of BAV-ATAA, (2) define surgical guidelines for elective intervention in patients with ATAA-BAV, and (3) characterize the behavior of spared bicuspid aortic valves during ATAA resection.

Methods: A retrospective review of the Yale Aortic Institute database was done to identify patients with ATAA-BAV. We calculated rate of growth, yearly rate of complications, 5-year event-free survival through a Kaplan-Meier curve, as well as a logistic regression that looked into risk of complications as a function of aortic size. Of these patients, the ones whose valve was spared at the time of surgery were further analyzed. Postoperative and preoperative echocardiograms were compared to determine changes in valve function of this smaller cohort.

Results: We identified 514 patients with ATAA-BAV through data collection. The mean growth rate of ATAA-BAV was 0.21 cm/year. The larger the aneurysm, the faster it grew. There was a 13% yearly rate of rupture, dissection, and death in patients with an ATAA diameter ≥ 6cm. These patients have a 13-fold increase risk of suffering an aortic complication compared to patients with an aortic size of 4-4.5 cm (p

Conclusion: Prophylactic size-based surgery in BAV-ATAA patients can be considered at 5.0 cm at expert aortic centers as a means to afford protection from natural complication. Non-expert center may wait for 5.5 cm. BAV free of aortic stenosis or insufficiency before surgery and “healthy” appearing at surgery can safely be preserved.

Open Access

This Article is Open Access

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