Kochav Jonathan D, Takayama Hiroo, Goldstone Andrew, Kalfa David, Bacha Emile, Rosenbaum Marlon, Lewis Matthew J
Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY.
Division of Cardiothoracic and Vascular Surgery, Department of Medicine, Columbia University Irving Medical Center, New York, NY.
JTCVS Open. 2024 Mar 27;19:47-60. doi: 10.1016/j.xjon.2024.03.006. eCollection 2024 Jun.
Bicuspid aortic valve (AV) patients with aortic regurgitation (AR) differ from tricuspid AV patients given younger age, greater left ventricle (LV) compliance, and more prevalent aortic stenosis (AS). Bicuspid AV-specific data to guide timing of AV replacement or repair are lacking.
Adults with bicuspid AV and moderate or greater AR who underwent aortic valve replacement or repair at our center were studied. The presurgical echocardiogram, and echocardiograms within 3 years postoperatively were evaluated for LV geometry/function, and AV function. Semiquantitative AS/AR assessment was performed in all patients with adequate imaging.
One hundred thirty-five patients (85% men, aged 44.5 ± 15.9 years) were studied (63% pure AR, 37% mixed AS/AR). Following aortic valve replacement or repair, change in LV end-diastolic dimension and change in LV end-diastolic volume were associated with preoperative LV end-diastolic dimension (β = 0.62 Δcm/cm; 95% CI, 0.43-0.73 Δcm/cm; < .001), and LV end-diastolic volume (β = 0.6 ΔmL/mL; 95% CI, 0.4-0.7 ΔmL/mL; < .001), respectively, each independent of AR/AS severity ( = not significant). Baseline LV size predicted postoperative normalization (LV end-diastolic dimension: odds ratio, 3.75/cm; 95% CI, 1.61-8.75/cm, LV end-diastolic volume: odds ratio, 1.01/mL; 95% CI, 1.004-1.019/mL, both values < .01) whereas AR/AS severity did not ( = not significant). Indexed LV end diastolic volume outperformed LV end-diastolic dimension in predicting postoperative LV normalization (area under the curve = 0.74 vs 0.61) with optimal diagnostic cutoffs of 99 mL/m and 6.1 cm, respectively. Postoperative indexed LV end diastolic volume dilatation was associated with increased risk of death, transplant/ventricular assist device, ventricular arrhythmia, and reoperation (hazard ratio, 6.1; 95% CI, 1.7-21.5; < .01).
Remodeling extent following surgery in patients with bicuspid AV and AR relates to preoperative LV size independent of valve disease phenotype or severity. Many patients with LV end-diastolic dimension below current surgical thresholds did not normalize LV size. LV volumetric assessment offered superior diagnostic performance for predicting residual LV dilatation, and postoperative indexed LV end diastolic volume dilatation was associated with adverse prognosis.
患有主动脉瓣反流（AR）的二叶式主动脉瓣（AV）患者与三叶式AV患者不同，前者年龄更小、左心室（LV）顺应性更高且主动脉狭窄（AS）更为普遍。目前缺乏指导二叶式AV置换或修复时机的特异性数据。
对在我们中心接受主动脉瓣置换或修复的患有二叶式AV且AR程度为中度或更严重的成人患者进行研究。对术前超声心动图以及术后3年内的超声心动图进行评估，以了解LV几何形状/功能以及AV功能。对所有具备充分影像资料的患者进行半定量AS/AR评估。
共研究了135例患者（85%为男性，年龄44.5±15.9岁）（63%为单纯AR，37%为混合性AS/AR）。在主动脉瓣置换或修复后，LV舒张末期内径的变化和LV舒张末期容积的变化分别与术前LV舒张末期内径（β=0.62Δcm/cm；95%CI，0.43 - 0.73Δcm/cm；P<0.001）以及LV舒张末期容积（β=0.6ΔmL/mL；95%CI，0.4 - 0.7ΔmL/mL；P<0.001）相关，且各自独立于AR/AS严重程度（P=不显著）。基线LV大小可预测术后恢复正常（LV舒张末期内径：比值比，3.75/cm；95%CI，1.61 - 8.75/cm，LV舒张末期容积：比值比，1.01/mL；95%CI，1.004 - 1.019/mL，两者P值<0.01），而AR/AS严重程度则不能（P=不显著）。在预测术后LV恢复正常方面，LV舒张末期容积指数优于LV舒张末期内径（曲线下面积=0.74对0.61），最佳诊断临界值分别为99mL/m²和6.1cm。术后LV舒张末期容积指数增大与死亡、移植/心室辅助装置、室性心律失常及再次手术风险增加相关（风险比，6.1；95%CI，1.7 - 21.5；P<0.01）。
患有二叶式AV和AR的患者术后重塑程度与术前LV大小有关，独立于瓣膜疾病表型或严重程度。许多LV舒张末期内径低于当前手术阈值的患者并未使LV大小恢复正常。LV容积评估在预测LV残余扩张方面具有更优的诊断性能，且术后LV舒张末期容积指数增大与不良预后相关。
