Aortic valve morphology and complications after aortic valve surgery in patients with bicuspid aortic valve disease
S Wulffeld, M D S Schmiegelow, R Oksjoki, D G Nielsen, N Eske Bruun, K ProcidaAbstract
Background
Bicuspid aortic valves (BAV) exhibit diverse morphological patterns. The two most common phenotypes are the 2-sinus BAV and the fused BAV. These phenotypes differ in their geometric characteristics, and their valve dysfunction may arise from distinct underlying pathophysiological mechanisms, both of which could influence outcomes following aortic valve replacement (AVR).
Purpose
To evaluate differences in short-term complications and long-term prognosis following aortic valve surgery among patients with bicuspid aortic valve according to valve morphology.
Methods
From a prospective cohort study of adult BAV outpatients followed in the period 2018-2024, we identified 276 cases who underwent AVR during follow-up and who had either a 2-sinus (n=44/15.9%) or fused (n=232/84.1%) BAV morphology. Short-term complications were assessed at 30-days following surgery and we compared a composite of re-interventions (redo-AVR, surgery to stop major bleeding, pericardiocentesis, or re-hospitalization with pleuracentesis) and all-cause mortality using logistic regression. Furthermore, the following complications were assessed at end of follow-up: re-do AVR, endocarditis, and all-cause mortality. We estimated the overall event-free survival using the Kaplan Meier-estimator and compared the hazard of having any of these events using Cox regression. We considered sex and age at time of surgery as possible confounders.
Results
Median age of the cohort was 62.5 [54.9, 69.3] years with no difference between morphology subgroups (p=0.6). Surgical details are compared between the subgroups in Table 1. Groups were very similar, with the exception that the frequency of pericardial patch repair during surgery was slightly higher in the 2-sinus BAV subgroup (9.1% vs. 1.3%, p=0.01). In total, 75 (27.2%) patients experienced one of the short-term complications and the risk was increased in patients with 2-sinus BAV (unadjusted odds ratio= 2.13, 95% CI (1.09; 4.16), p=0.03) and (adjusted odds ratio=2.26, 95%CI (1.14; 4.46), p=0.02). During a median follow-up of 4.4 years (interquartile range: 2.1- 5.6), there were 10 cases (3.6%) of endocarditis, 8 re-do surgeries (2.9%) and 10 patients died (3.6%). In total, 14 patients developed a primary composite endpoint and the estimated event-free survival 5 years after surgery was 89.4%, 95%CI (85.3%; 93.6%). The hazard of the composite endpoint was higher in patients with 2-sinus BAV with a crude hazard ratio of 2.34, (95% CI (0.97; 5.64), p = 0.06) and an adjusted hazard ratio of 2.62 (95%CI (1.08; 6.35), p=0.03, figure 1 Cumu).
Conclusion
In this observational study of bicuspid aortic valve patients undergoing aortic valve surgery, a 2-sinus BAV morphology was associated with increased risks of short-term and longer-term complications.