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Commentary: Aortic replacement for bicuspid aortic valve disease—How much is too much (or too little)?

  • Peter J. Altshuler
    Affiliations
    Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
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  • Pavan Atluri
    Correspondence
    Address for reprints: Pavan Atluri, MD, Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein, Philadelphia, PA 19104.
    Affiliations
    Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
    Search for articles by this author
Published:October 04, 2019DOI:https://doi.org/10.1016/j.jtcvs.2019.09.114
      Figure thumbnail fx1
      Peter J. Altshuler, MD (left), and Pavan Atluri, MD (right)
      Recommendations for ascending aortic replacement for bicuspid aortic valve do not include extent of resection. With stratification of valvular phenotypes, tailored therapy may dictate treatment.
      See Article page 12.
      Bicuspid aortic valve disease is one of the most common congenital cardiac malformations encountered. Although it is classified as a single pathology, recent findings suggest that bicuspid aortic valve disease may represent a heterogeneous range of phenotypes yielding a similar fusion of aortic valve leaflets.
      • Detaint D.
      • Michelena H.I.
      • Nkomo V.T.
      • Vahanian A.
      • Jondeau G.
      • Sarano M.E.
      Aortic dilatation patterns and rates in adults with bicuspid aortic valves: a comparative study with Marfan syndrome and degenerative aortopathy.
      Nevertheless, bicuspid valvular disease is frequently associated with ascending aortopathy,
      • Michelena H.I.
      • Khanna A.D.
      • Mahoney D.
      • Margaryan E.
      • Topilsky Y.
      • Suri R.M.
      • et al.
      Incidence of aortic complications in patients with bicuspid aortic valves.
      ,
      • El-Hamamsy I.
      • Yacoub M.H.
      A measured approach to managing the aortic root in patients with bicuspid aortic valve disease.
      and current European and American guidelines advocate for selective ascending aortic replacement, depending on the extent of aneurysmal degeneration at the time of valve repair.
      • 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease Representative Members
      • Hiratzka L.F.
      • Creager M.A.
      • Isselbacher E.M.
      • Svensson L.G.
      • 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease Representative Members
      • et al.
      Surgery for aortic dilatation in patients with bicuspid aortic valves: a statement of clarification from the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
      • Vahanian A.
      • Alfieri O.
      • Andreotti F.
      • Antunes M.J.
      • Barón-Esquivias G.
      • Baumgartner H.
      • et al.
      ESC Committee for Practice Guidelines (CPG)Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC)European Association for Cardio-Thoracic Surgery (EACTS)
      Guidelines on the management of valvular heart disease (version 2012): the joint task force on the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio- Thoracic Surgery (EACTS).
      • Borger M.A.
      • Fedak P.W.M.
      • Stephens E.H.
      • Gleason T.G.
      • Girdauskas E.
      • Ikonomidis J.S.
      • et al.
      The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: executive summary.
      Despite consensus on the necessity for ascending aortic replacement, controversy exists regarding the extent of distal reconstruction. Distal anastomosis technique dictates many factors that are likely to affect postoperative outcomes, and although conclusions from current literature draw from an abundance of short-term outcomes, no consensus has been drawn regarding operative technique. More importantly, generalizability of techniques and recommendations of intervention are often predicated on the individual surgeon's comfort with a clamped versus open hemiarch reconstruction.
      In this issue of the Journal, Greason and colleagues
      • Greason K.L.
      • Crestanello J.A.
      • King K.S.
      • Bagameri G.
      • Cicek S.M.
      • Stulak J.M.
      • et al.
      Open hemiarch versus clamped ascending aorta replacement for aortopathy during initial bicuspid aortic valve replacement.
      compare hemiarch versus clamped ascending aortic replacement in patients with bicuspid aortic valve disease in the absence of aortic arch dilation. In a single-institution retrospective analysis, outcomes related to in-hospital complications, reoperation for aortic arch disease, and survival were compared between patients undergoing hemiarch or clamped ascending aortic reconstruction in largely similar patient cohorts. Both groups demonstrated largely similar outcomes for survival and reoperation for arch disease, correlating to previous findings by Sultan and associates.
      • Sultan I.
      • Bianco V.
      • Yazji I.
      • Kilic A.
      • Dufendach K.
      • Cardounel A.
      • et al.
      Hemiarch reconstruction versus clamped aortic anastomosis for concomitant ascending aortic aneurysm.
      Importantly, and again similar to previously published data,
      • Sultan I.
      • Bianco V.
      • Yazji I.
      • Kilic A.
      • Dufendach K.
      • Cardounel A.
      • et al.
      Hemiarch reconstruction versus clamped aortic anastomosis for concomitant ascending aortic aneurysm.
      • Malaisrie S.C.
      • Duncan B.F.
      • Mehta C.K.
      • Badiwala M.V.
      • Rinewalt D.
      • Kruse J.
      • et al.
      The addition of hemiarch replacement to aortic root surgery does not affect safety.
      • Bilkhu R.
      • Youssefi P.
      • Soppa G.
      • Theodoropoulus P.
      • Phillips S.
      • Liban B.
      • et al.
      Fate of the aortic arch following surgery on the aortic root and ascending aorta in bicuspid aortic valve.
      whereas hemiarch was associated with longer cardiopulmonary bypass times and greater postoperative transfusion requirements, patients with clamped ascending repairs had higher rates of return to the operating room for bleeding.
      Many important facets reflecting current understanding of bicuspid aortic valve disease and associated aortopathy are demonstrated both in the strengths of Greason and colleagues' observations
      • Greason K.L.
      • Crestanello J.A.
      • King K.S.
      • Bagameri G.
      • Cicek S.M.
      • Stulak J.M.
      • et al.
      Open hemiarch versus clamped ascending aorta replacement for aortopathy during initial bicuspid aortic valve replacement.
      and in their study limitations. Overall, it appears the technical and circulatory considerations of hemiarch anastomosis relative to clamped ascending aortic reconstruction must be carefully balanced with longer cardiopulmonary bypass times and the need for circulatory arrest. Although hemiarch repair is associated with decreased rates of return to the operating room for bleeding,
      • Greason K.L.
      • Crestanello J.A.
      • King K.S.
      • Bagameri G.
      • Cicek S.M.
      • Stulak J.M.
      • et al.
      Open hemiarch versus clamped ascending aorta replacement for aortopathy during initial bicuspid aortic valve replacement.
      ,
      • Sultan I.
      • Bianco V.
      • Yazji I.
      • Kilic A.
      • Dufendach K.
      • Cardounel A.
      • et al.
      Hemiarch reconstruction versus clamped aortic anastomosis for concomitant ascending aortic aneurysm.
      the known risks of increased time on bypass and theoretic concerns regarding the use of hypothermic circulatory arrest complicate the picture,
      • Salis S.
      • Mazzanti V.V.
      • Merli G.
      • Salvi L.
      • Tedesco C.C.
      • Veglia F.
      • et al.
      Cardiopulmonary bypass duration is an independent predictor of morbidity and mortality after cardiac surgery.
      albeit without considerable adverse outcome in recent published series from experienced centers. A paucity of recurrent arch disease throughout the literature suggests efficacy of both repairs, although the limited follow-up within published series leaves this question largely open.
      Greason and colleagues
      • Greason K.L.
      • Crestanello J.A.
      • King K.S.
      • Bagameri G.
      • Cicek S.M.
      • Stulak J.M.
      • et al.
      Open hemiarch versus clamped ascending aorta replacement for aortopathy during initial bicuspid aortic valve replacement.
      do help shed further light on this important question regarding bicuspid aortic valve disease, and their outcomes reflect their group's commitment to improving patient care. Ultimately, their data aid in selection of the appropriate repair for patients with bicuspid aortic valve disease in the absence of arch dilation, while paving the way for future research to help customize care in a heterogeneous patient population.

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