Factors related to the need for surgery after the diagnosis of bicuspid aortic valve: one center´s experience under a conservative approach.

BACKGROUND AND AIM: Bicuspid aortic valve (BAV) increases the risk of aortic valve dysfunction and ascending aorta aneurysm and, consequently, the need for aortic valve replacement and/or aortic repair. However, there is no universal consensus about the surgical criteria and the predictors for surgery. The aim of this study was to investigate related factors to the need for surgery in the setting of a strict long-term follow-up with relatively conservative surgical criteria. METHODS: We prospectively followed 120 patients after the diagnosis of BAV. Predisposing factors for a future need for aortic valve replacement and ascending aorta repair were assessed. Aortic surgery was indicated when the ascending aorta diameter was ≥ 55 mm and was recommended based on patient characteristics and in the presence of a severe aortic valve dysfunction with an aortic diameter ≥ 50 mm. RESULTS: During follow-up (mean, 86 months), 34 patients (28%) (mean age, 56 ± 12 years) were surgically treated. Aortic valve dysfunction (n=22; 64%) and ascending aorta dilatation (n=12; 36%) were the indications for surgery. Aortic regurgitation was the most frequent valve dysfunction at the time of diagnosis for BAV, but aortic stenosis was the most frequent indication for surgery. The presence at surgery of either aortic regurgitation or stenosis was clearly related to age, with regurgitation predominating in patients under 55 years, and aortic stenosis in older patients.Multivariate Cox analysis showed that aortic stenosis (hazard ratio 4.1, p=0.001), indexed ascending aorta dilatation (hazard ratio 3.0, p=0.03) and left ventricular end-diastolic diameter ≥ 60 mm (hazard ratio=4.0, p=0.01) at diagnosis were factors associated with future surgery. Aortic dissection was not observed in patients that did not undergo surgery. CONCLUSIONS: A relatively conservative approach for the indication of ascending aortic surgery in BAV is safe. In this setting, the presence of aortic or left ventricle dilatation and aortic stenosis at diagnosis of BAV were predictive of the need for surgery in the follow-up.

[Effect of age on valvular dysfunction and aortic dilatation in patients with a bicuspid aortic valve]. / Efecto de la edad en la disfunción valvular y la dilatación aórtica en pacientes con válvula aórtica bicúspide.

Aortic regurgitation was the commonest functional anomaly among younger patients in a group of 63 individuals with a diagnosis of bicuspid aortic valve. With increasing age, a rise in the number with combined aortic valve disease and aortic stenosis was observed. Aortic dilatation was found in 65% of cases. Dilatation was independently associated with age and transvalvular aortic gradient.

Efecto de la edad en la disfunción valvular y la dilatación aórtica en pacientes con válvula aórtica bicúspide / Effect of age on valvular dysfunction and aortic dilatation in patients with a bicuspid aortic valve

En 63 pacientes diagnosticados de válvula aórtica bicúspide, la insuficiencia aórtica fue la alteración funcional más frecuente en los pacientes más jóvenes, mientras que con el envejecimiento se observó un aumento de casos con doble lesión y estenosis aórtica. Se detectó una dilatación aórtica en el 65% de los casos. La edad y el gradiente transvalvular aórtico eran factores independientes relacionados con la dilatación (AU)

Aortic regurgitation was the commonest functional anomaly among younger patients in a group of 63 individuals with a diagnosis of bicuspid aortic valve. With increasing age, a rise in the number with combined aortic valve disease and aortic stenosis was observed. Aortic dilatation was found in 65% of cases. Dilatation was independently associated with age and transvalvular aortic gradient (AU)

Aortic valve morphology definition with transthoracic combined with transesophageal echocardiography in a population with high prevalence of bicuspid aortic valve.

OBJECTIVE: To assess the utility of transthoracic echocardiography (TTE) with second harmonic combined with transesophageal echocardiography (TEE) in defining aortic valve morphology in a subset of patients with a high prevalence of bicuspid aortic valve. METHODS AND MATERIALS: Patients (n = 174) with dilated aortic root were consecutively evaluated using, initially, TTE. The aortic valve structure was assigned as tricuspid, bicuspid or undefined. In those assigned as bicuspid or undefined, TEE was performed. Other factors that could affect valve morphology assignment were recorded and evaluated in multivariate analysis. RESULTS: TTE was able to characterise 89% of the tricuspid valves and 56% of the bicuspid. Bicuspid structure was the only variable that, in the multivariate analysis, was related to the inability to definitively assign aortic valve morphology (OR = 0.13). TEE was performed in 59 patients and the morphology was definitively assigned in 56 of them (95%). TEE diagnosed 15 bicuspid valves in addition to confirming the 17 identified by TTE. Overall, using TTE combined with TEE we were able to correctly assign valvular morphology in 98% of patients. CONCLUSION: In a subset of patients with a high prevalence of bicuspid aortic valve, combination of TTE and TEE should be considered to define aortic valve morphology. TEE identifies an important number of patients with BAV.

Factors related to aortic regurgitation in the presence of a dilated aortic root.

The relation among aortic regurgitation (AR) and aortic root diameter, anthropometric variables, and aortic valve morphology was assessed in 142 patients with dilated aortic roots. The diameter of the aortic root indexed for body surface area and aortic valve sclerosis were related to the presence and severity of AR.

Restrictive left ventricular filling and preserved ventricular function: a limitation in the noninvasive estimation of pulmonary wedge pressure by Doppler echocardiography.

Pulmonary wedge pressure (PWP) can be estimated from the ratio of transmitral early peak flow velocity to flow propagation velocity measured by Doppler. Discrepancies observed in the application of the method prompted us to design this prospective study, aimed at detecting potential limitations of the method. We studied a total of 32 patients admitted to a cardiac intensive care unit, using a Swan-Ganz catheter. Correlation between invasive- and Doppler-estimated PWP was fairly good (r = 0.58). Analysis of discrepant cases led to the identification of a subgroup of 6 patients in whom PWP was largely underestimated because of unexpectedly high values of flow propagation velocity (71 +/- 15 cm/s vs 37 +/- 10 cm/s in the rest of the group; P =.0001). All of them had in common a restrictive Doppler filling pattern and preserved left ventricular systolic function. Exclusion of this group showed an improvement in the correlation coefficient to r = 0.72. In conclusion, PWP can be estimated by the Doppler early peak flow velocity to flow propagation velocity ratio, although a significant underestimation of PWP may be observed in patients with a restrictive filling pattern and preserved ventricular function.