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Predictors of proximal aortic dissection at the time of aortic valve replacement
Y von Kodolitsch1, O Simic, A Schwartz
1Department of Internal Medicine, Division of Cardiology, University Hospital Eppendorf, Hamburg, Germany.
Insights
Predictors of late aortic dissection after aortic valve replacement (AVR) include aortic regurgitation and fragile, thinned aortic walls. These findings highlight risks in patients with aortic root disease undergoing incomplete AVR.
Area of Science:
- Cardiovascular Surgery
- Aortic Disease
- Valvular Heart Disease
Background:
- Type I aortic dissection occurs late in 0.6% of patients post-aortic valve replacement (AVR).
- A history of AVR is present in 13% of patients with type I aortic dissections.
- Predictors of aortic dissection at the time of AVR are not well-characterized.
Purpose of the Study:
- To identify predictors of late type I aortic dissection after AVR.
- To investigate factors associated with aneurysm formation after AVR.
Main Methods:
- Retrospective analysis of 33 patients with type I aortic dissection post-AVR.
- Comparison with 101 controls without aortic diameter progression post-AVR.
- Multivariate analysis to identify predictors of dissection and aneurysm formation.
Main Results:
- Aortic regurgitation (14%), fragile aortic walls (22%), and thinned aortic walls (7%) at AVR predicted late dissection.
- Aortic clamping time, prosthesis type, CABG, and initial aortic diameter did not predict dissection.
- Younger age at AVR and bicuspid aortic valves predicted late aneurysm formation.
Conclusions:
- Aortic regurgitation with fragile, thinned aortic walls suggests aortic root disease.
- Incomplete treatment of aortic root disease via isolated AVR increases risk of late aortic sequelae.
- Early identification of these predictors can guide surgical management and risk stratification.
Background:
Type I aortic dissection develops in 0.6% of patients late after aortic valve replacement (AVR), and 13% of patients with type I aortic dissections have a history of AVR. Predictors of aortic dissection at AVR, however, have not been characterized.
Methods And Results:
A study group of 33 patients with type I aortic dissection had aortic surgery 49+/-55 months after routine AVR. A group of 101 controls, who did not have morphological progression of aortic diameters >/=6 years after AVR, was used to identify predictors of postsurgical dissection. Multivariate analysis identified aortic regurgitation (P<0.002) and fragility (P<0.001) or thinning of the aortic wall (P<0.007) at AVR as predictors, associated with a 14%, 22%, and 7% probability of late aortic dissection, respectively. Clamping times, types of valve prostheses, concomitant coronary artery bypass grafting, and mean ascending aortic diameters of 43+/-10 mm at AVR did not predict late dissection. A separate analysis of 29 nondissecting aneurysms of the ascending aorta developing 104+/-64 months after routine AVR revealed younger age at AVR (P<0.003) and congenitally bicuspid aortic valves (P<0.03) as predictors of late aneurysm formation.
Conclusions:
Aortic regurgitation combined with fragile and thinned aortic walls in patients with moderate aortic dilation may reflect aortic root disease, with a high risk for postsurgical aortic sequelae if it is treated incompletely by isolated valve replacement.
