Wang Yongshi, Wu Boting, Li Jun, Dong Lili, Wang Chunsheng, Shu Xianhong
Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital Fudan University, Shanghai, China; Shanghai Institute of Medical Imaging, Zhongshan Hospital Fudan University, Shanghai, China.
Department of Transfusion, Zhongshan Hospital Fudan University, Shanghai, China.
Ann Thorac Surg. 2016 May;101(5):1707-14. doi: 10.1016/j.athoracsur.2015.10.047. Epub 2016 Jan 12.
Aberrant flow pattern and congenital fragility bestows bicuspid aortic valve (BAV) with a propensity toward ascending aorta dilatation, aneurysm, and dissection. Whether isolated aortic valve replacement (AVR) can prevent further dilatation in BAV ascending aorta and what indicates concurrent aortic intervention in the case of valve operation remain controversial.
From June 2006 to January 2009, patients with a BAV who underwent isolated AVR were consecutively included and categorized into aortic insufficiency (BAV-AI, n = 84) and aortic stenosis (n = 112) groups, and another population of patients with a tricuspid aortic valve with aortic insufficiency (n = 149) was also recruited during the same period for comparison of annual aortic dilatation rate and adverse aortic events after isolated AVR.
With a median follow-up period of 72 months (interquartile range, 66 to 78 months), ascending aorta dilatation rates were faster in the BAV-AI group than the BAV plus aortic stenosis and tricuspid aortic valve with aortic insufficiency groups (both p < 0.001). The BAV-AI group showed a higher risk for adverse aortic events compared with both the BAV plus aortic stenosis (15.5% versus 4.5%; p = 0.008) and tricuspid aortic valve with aortic insufficiency (15.5% versus 6.0%; p = 0.018) groups. Cox regression analysis identified aortic insufficiency (hazard ratio, 3.7; 95% confidence interval, 1.2 to 11.1; p = 0.019) as an independent risk factor for adverse aortic events among patients with BAV in general, whereas preoperative ascending aortic diameter larger than 45 mm (hazard ratio, 13.8; 95% confidence interval, 3.0 to 63.3; p = 0.001) served as a prognostic indicator in the BAV-AI group.
An aggressive policy of preventive aortic interventions seemed appropriate in patients with BAV-AI during AVR, and BAV phenotype presenting as either insufficiency or stenosis should be taken into consideration when contemplating optimal surgical strategies for BAV aortopathy.
异常血流模式和先天性脆弱性使二叶式主动脉瓣（BAV）易于发生升主动脉扩张、动脉瘤和夹层。单纯主动脉瓣置换术（AVR）能否预防BAV患者升主动脉进一步扩张，以及在瓣膜手术时哪些情况提示需要同期进行主动脉干预，仍存在争议。
2006年6月至2009年1月，连续纳入接受单纯AVR的BAV患者，并分为主动脉瓣关闭不全（BAV-AI，n = 84）和主动脉瓣狭窄（n = 112）组，同期还纳入了另一组三尖瓣主动脉瓣合并主动脉瓣关闭不全的患者（n = 149），以比较单纯AVR术后的年度主动脉扩张率和主动脉不良事件。
中位随访期为72个月（四分位间距，66至78个月），BAV-AI组的升主动脉扩张率高于BAV合并主动脉瓣狭窄组和三尖瓣主动脉瓣合并主动脉瓣关闭不全组（均p < 0.001）。与BAV合并主动脉瓣狭窄组（15.5%对4.5%；p = 0.008）和三尖瓣主动脉瓣合并主动脉瓣关闭不全组（15.5%对6.0%；p = 0.018）相比，BAV-AI组发生主动脉不良事件的风险更高。Cox回归分析确定，一般BAV患者中，主动脉瓣关闭不全（风险比，3.7；95%置信区间，1.2至11.1；p = 0.019）是主动脉不良事件的独立危险因素，而在BAV-AI组中，术前升主动脉直径大于45 mm（风险比，13.8；95%置信区间，3.0至63.3；p = 0.001）是一个预后指标。
对于BAV-AI患者，在AVR期间采取积极的预防性主动脉干预策略似乎是合适的，在考虑BAV主动脉病变的最佳手术策略时，应考虑表现为关闭不全或狭窄的BAV表型。
