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Aortic dissection after aortic valve replacement: incidence and consequences for strategy
K Prenger1, F Pieters, E Cheriex
1Department of Cardiothoracic Surgery, University Hospital Maastricht, The Netherlands.
Insights
Aortic valve replacement (AVR) patients with aortic diameters over 50 mm face a significantly higher risk of acute aortic dissection. Early reoperation is recommended for these patients, especially those with hypertension.
Area of Science:
- Cardiovascular Surgery
- Aortic Diseases
- Cardiac Imaging
Background:
- Aortic valve replacement (AVR) is a common procedure, but complications can arise.
- Acute aortic dissection is a rare but severe complication following AVR.
- Pre-existing aortic dilatation may increase the risk of dissection post-AVR.
Purpose of the Study:
- To investigate the incidence and risk factors of acute aortic dissection after AVR.
- To determine the relationship between aortic diameter and dissection risk in AVR patients.
- To establish guidelines for managing aortic dilatation in patients who have undergone AVR.
Main Methods:
- Retrospective analysis of 10 patients who developed acute aortic dissection post-AVR.
- Echocardiographic database review of 33,105 studies in 21,484 patients.
- Comparison of aortic dimensions and dissection incidence in AVR patients with and without aortic dilatation.
Main Results:
- All 10 observed dissections occurred in patients with an aortic diameter ≥ 50 mm (mean 64 mm).
- In patients with AVR and aortic size > 50 mm, dissection incidence was 27% vs. 0.6% overall.
- Systemic hypertension was a common comorbidity (70%) in patients with dissection.
Conclusions:
- Aortic dilatation (≥ 50 mm) is a critical risk factor for acute aortic dissection after AVR.
- Valved conduit implantation is indicated even with mild annuloaortic ectasia (aortic size ≥ 50 mm).
- Elective reoperation is advised for AVR patients with enlarging aortic diameter > 50 mm, particularly if hypertensive.
Abstract:
From 1986 to 1994, 10 patients were observed to have developed an acute aortic dissection at some stage after an aortic valve replacement (AVR). Study of the characteristics of these patients showed that all patients had an aortic diameter of 50 mm or more (range 50 to 80 mm, mean 64 mm), and 70% suffered from systemic hypertension. Subsequently, the echocardiographic database, containing data from 33,105 studies in 21,484 patients, was searched for cases of AVR in which an accurate aortic dimension could be measured. Of 524 patients who had undergone AVR, an accurate aortic diameter was recorded in 419. Thirty-seven patients had an aortic size greater than 50 mm. All acute dissections occurred in this group of patients. The incidence of acute dissections among patients with significant aortic dilatation following AVR was 27%, whereas the overall incidence of acute dissection after AVR is 0.6%. Although there was a preponderance of tilting disc mechanical valves in the dissecting patients, the type of valve implanted does not seem to be of any importance. From these observations, we conclude that implantation of a valved conduit is indicated even in the presence of mild annuloaortic ectasia (aortic size = 50 mm). Patients who have had an AVR and show an enlarging aortic diameter exceeding 50 mm should have an elective reoperation at an early stage, especially when systemic hypertension is present.