289. Long-Term Outcomes of Root Stabilization Procedures for Heterogenous Ascending Aneurysm Pathologies in Bicuspid Aortic Valve Syndrome
Rita Karianna Milewski, Andreas Habertheur, *Joseph E. Bavaria, Maham Suhail, Mary Siki, Robert Hu, Melanie Freas, Chirag Ram, *Nimesh D. Desai, Ananya Nanduri, *Wilson Y. Szeto, *Prashanth Vallabhajosyula
University of Pennsylvania, Philadelphia, PA
Invited Discussant: *Thomas E. MacGillivray
Objective: Surgical management for bicuspid aortic valve (BAV) syndrome, a heterogeneous disease involving valvular and ascending aneurysm pathologies, typically entails the following options: Bentall root replacement, aortic valve replacement with supracoronary ascending aorta replacement(AVRSCAAR), and valve sparing root reimplantation (VSRR). We performed a comparative analysis of the long-term clinical and functional outcomes of these surgical approaches for managing BAV ascending aortopathies.
Methods: From 1998 to 2017, 635 BAV patients undergoing elective root stabilization procedures at a single institution were stratified by valvular pathology, aortic stenosis (AS; n=326) and aortic insufficiency (AI; n=309); and further substratified by surgical intervention: AS group- Bentall (n=148:biologic=102, mechanical=46), AVRSCAAR (n=178: biologic=167, mechanical=11), and AI group- Bentall (n=169:biologic=109, mechanical=60), AVRSCAAR (n=76:biologic=74, mechanical=2), VSRR (n=64). Subjects were matched by inverse probability weights calculated by log regression for analysis of long-term clinical and functional outcomes.
Results: Kaplan-Meier curves for all-cause mortality were similar between Bentall versus AVRSCAAR for AS and AI presentations (log-rank p>0.05). In AS patients, multivariable Cox regression analysis for all-cause mortality, stroke, and Major Adverse Valve Related Events (MAVRE: structural valve degeneration, aortic reoperation, stroke/ TIA, mortality) showed significantly decreased risk of stroke in biologic AVRSCAAR compared to mechanical Bentall (HR 0.04, p=0.013) (Fig.1A). Repeated measures mixed effects model showed similar transvalvular gradients over long-term (p=0.122). Transition state model for new onset >moderate AI were also similar (p=0.987). Competing-risks regression analysis for aortic reoperation showed similar rates between Bentall versus AVRSCAAR (p=0.353), regardless of mechanical or biologic valve (p=0.859).
In AI patients, Cox regression analysis showed similar long-term risk of mortality (HR 0.95, p=0.93), but lower MAVRE and stroke risk in biologic AVRSCAAR group (Fig.1B). Aortic reoperation rate was significantly lower in AVRSCAAR (coefficient <0.01, p<0.001) by competing-risks regression analysis. Functional outcomes were similar. In a concurrent series comparing Bentall AI to VSRR, MAVRE (HR 0.14, p=0.043) and mortality (HR 0.12, p=0.022) by multivariable Cox regression were significantly improved in VSRR subjects (Fig.1C), but recurrence of AI was significantly higher with VSRR (coefficient 2.63, p<0.001) by transition state model analysis.
Conclusions: A tailored approach to heterogeneous BAV aortopathies utilizing Bentall, AVRSCAAR, and VSRR procedures render excellent long-term clinical and functional outcomes, with improved outcomes seen in biologic AVRSCAAR patients.