Aorta Center, Cleveland, Ohio; Bicuspid Aortic Valve Center, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland, Ohio.
Department of Thoracic and Cardiovascular Surgery, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio.
J Thorac Cardiovasc Surg. 2024 Feb;167(2):566-577.e9. doi: 10.1016/j.jtcvs.2022.05.001. Epub 2022 May 15.
Consensus has not been reached on whether or not to replace or preserve a well-functioning bicuspid aortic valve (BAV) in patients undergoing aortic replacement for the ascending phenotype of BAV aortopathy. We characterize morphology, evaluate progression of aortic regurgitation or aortic stenosis, and investigate the need for aortic valve replacement in patients whose well-functioning BAV was preserved during ascending aortic replacement ≥10 years prior.
From January 1991 to August 2011, 191 patients with a well-functioning BAV underwent supracoronary aortic replacement (113 valves were minimally repaired). Aortic morphology was evaluated, aortic regurgitation grade and transvalvular aortic gradient modeled parametrically, and survival assessed by the Kaplan-Meier method. Median follow-up was 10 years.
Mean aortic diameter was 2.9 ± 0.53 cm at the annulus and 4.2 ± 0.55 cm at the sinuses. Mean maximum ascending diameter was 5.1 ± 0.49 cm. All patients exhibited a cusp-fusion BAV phenotype. Fifteen-year progression to severe aortic regurgitation was 3.2%. Mean aortic valve gradient began to rise 5 years postoperatively to 27 mm Hg by 14 years. Freedom from aortic valve replacement at 1, 5, 10, and 15 years was 100%, 95%, 83%, and 63%, respectively. Minimal valve repair was not associated with late aortic valve replacement. Fifteen-year survival was 74%.
Preserving a well-functioning BAV should be considered in carefully selected patients undergoing aortic replacement for the ascending phenotype of BAV aortopathy. The valves remain durable in the long term, with slow progression of regurgitation or stenosis, and low probability of aortic valve replacement through 10 years.
对于因二叶式主动脉瓣（BAV）升主动脉病变而行主动脉置换术的患者，对于是否替换或保留功能良好的二叶式主动脉瓣，目前尚未达成共识。我们对形态学进行了描述，评估了主动脉瓣反流或主动脉瓣狭窄的进展情况，并研究了在 10 年以上前接受升主动脉置换术时保留功能良好的二叶式主动脉瓣的患者是否需要行主动脉瓣置换术。
1991 年 1 月至 2011 年 8 月，191 例功能良好的二叶式主动脉瓣患者接受了冠状动脉上主动脉置换术（113 例瓣叶行最小程度修复）。评估主动脉形态，对主动脉瓣反流分级和跨瓣主动脉梯度进行参数建模，并采用 Kaplan-Meier 方法评估生存率。中位随访时间为 10 年。
瓣环处平均主动脉直径为 2.9 ± 0.53cm，窦部为 4.2 ± 0.55cm。平均升主动脉最大直径为 5.1 ± 0.49cm。所有患者均表现为瓣叶融合的二叶式主动脉瓣形态。15 年时严重主动脉瓣反流的进展率为 3.2%。术后 5 年主动脉瓣梯度开始升高，至 14 年时平均达到 27mmHg。1、5、10、15 年时免于主动脉瓣置换的比例分别为 100%、95%、83%和 63%。行最小程度瓣叶修复与晚期行主动脉瓣置换术无关。15 年生存率为 74%。
对于因二叶式主动脉瓣升主动脉病变而行主动脉置换术的患者，应慎重考虑保留功能良好的二叶式主动脉瓣。在长期随访中，这些瓣膜仍具有耐久性，其反流或狭窄进展缓慢，10 年内行主动脉瓣置换术的概率较低。
