Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
J Thorac Cardiovasc Surg. 2013 Nov;146(5):1033-1040.e4. doi: 10.1016/j.jtcvs.2013.06.037. Epub 2013 Aug 26.
Clinical practice guidelines have been established for surgical management of the aorta in bicuspid aortic valve disease. We hypothesized that surgeons' knowledge of and attitudes toward bicuspid aortic valve aortopathy influence their surgical approaches.
We surveyed cardiac surgeons to probe the knowledge of, attitudes toward, and surgical management of bicuspid aortopathy. A total of 100 Canadian adult cardiac surgeons participated.
Fifty-two percent of surgeons believed that the mechanism underlying aortic dilation in those with bicuspid aortic valve was due to an inherent genetic abnormality of the aorta, whereas only 2% believed that altered valve-related processes were involved in this process. Only a minority (15%) believed that bicuspid valve leaflet fusion type is associated with a unique pattern of aortic dilatation aortic phenotype. Sixty-five percent of surgeons recommended echocardiographic screening of first-degree relatives of patients with bicuspid aortic valve. Most surgeons (61%) elected to replace the aorta when the diameter is 45 mm or greater at the time of valve surgery. Fifty-five percent of surgeons surveyed suggested that in the absence of concomitant valvular disease, they would recommend ascending aortic replacement at a threshold of 50 mm or greater. Approximately one third of surgeons suggested that they would elect to replace a mildly dilated ascending aorta (40 mm) at the time of valve surgery. The most common surgical approach (61%) for combined valve and aortic surgery was aortic valve replacement and supracoronary replacement of the ascending aorta, and only a minority suggested the use of deep hypothermic circulatory arrest and open distal anastomosis. More aggressive approaches were favored with greater surgeon experience, and when circulatory arrest was chosen, the majority (68%) suggested they would use antegrade cerebral perfusion. In the setting of aortic insufficiency and a dilated aorta, 42% of surgeons suggested that they would perform valve-sparing surgery. Of note, 40% of respondents used an index measure of aortic size to body surface area in addition to absolute aortic diameter in assessing the threshold for intervention.
This large survey uncovered significant gaps in the knowledge and attitudes of surgeons toward the diagnosis and management of bicuspid aortopathy, many of which were at odds with current guideline recommendations. Efforts to promote knowledge translation in this area are strongly encouraged.
已有针对二叶式主动脉瓣病变主动脉外科治疗的临床实践指南。我们假设，外科医生对二叶式主动脉瓣病变主动脉瓣病变的认识和态度会影响他们的手术方法。
我们对心脏外科医生进行了调查，以探究他们对二叶式主动脉瓣病变主动脉瓣病变的了解、态度和手术处理方法。共有 100 名加拿大成人心脏外科医生参与了这项研究。
52%的外科医生认为，二叶式主动脉瓣患者主动脉扩张的机制是主动脉固有的遗传异常所致，而只有 2%的外科医生认为涉及到改变瓣膜相关的过程。只有少数（15%）外科医生认为二叶式瓣叶融合类型与独特的主动脉扩张主动脉表型相关。65%的外科医生建议对二叶式主动脉瓣患者的一级亲属进行超声心动图筛查。大多数外科医生（61%）建议在瓣膜手术时主动脉直径达到或大于 45mm 时进行主动脉置换。55%的被调查外科医生建议，如果没有合并瓣膜疾病，他们将建议在直径达到或大于 50mm 时进行升主动脉置换。大约三分之一的外科医生建议在瓣膜手术时对轻度扩张的升主动脉（40mm）进行置换。最常见的联合瓣膜和主动脉手术的外科手术方法（61%）是主动脉瓣置换和升主动脉冠状动脉以上置换，只有少数建议使用深低温停循环和开放远端吻合。随着外科医生经验的增加，更激进的方法得到了青睐，当选择停循环时，大多数（68%）建议使用顺行性脑灌注。在主动脉瓣关闭不全和主动脉扩张的情况下，42%的外科医生建议行保留瓣膜手术。值得注意的是，40%的受访者在评估介入阈值时，除了主动脉直径绝对值外，还使用了主动脉大小与体表面积的指数测量。
这项大型调查揭示了外科医生在诊断和处理二叶式主动脉瓣病变主动脉瓣病变方面存在的知识和态度方面的显著差距，其中许多与当前的指南建议相矛盾。强烈鼓励在该领域开展促进知识转化的工作。
