Effect of coronary bypass and valve structure on outcome in isolated valve replacement for aortic stenosis.

Reports differ regarding the effect of concomitant coronary artery bypass grafting (CABG) in patients who undergo aortic valve replacement (AVR) for aortic stenosis (AS), and no reports have described the effect of aortic valve structure in patients who undergo AVR for AS. A total of 871 patients aged 24 to 94 years (mean 70) whose AVR for AS was their first cardiac operation, with or without first concomitant CABG, were included. Patients who underwent mitral valve procedures were excluded. In comparison with the 443 patients (51%) who did not undergo CABG, the 428 (49%) who underwent concomitant CABG were significantly older, were more often male, had lower transvalvular peak systolic pressure gradients and larger valve areas, had lower frequencies of congenitally malformed aortic valves, had lighter valves by weight, had higher frequencies of systemic hypertension, and had longer stays in the hospital after AVR. Early and late (to 10 years) mortality were similar by propensity-adjusted analysis in patients who did and did not undergo concomitant CABG. Congenitally unicuspid or bicuspid valves occurred in approximately 90% of those aged 21 to 50, in nearly 70% in those aged 51 to 70 years, and in just over 30% in those aged 71 to 95 years. Unadjusted and adjusted survival was significantly higher in patients with unicuspid or bicuspid valves compared to those with tricuspid valves. In conclusion, although concomitant CABG had no effect on the adjusted probability of survival, the type of aortic valve (unicuspid or bicuspid vs tricuspid) significantly affected the unadjusted and adjusted probability of survival.

Presence of a congenitally bicuspid aortic valve among patients having combined mitral and aortic valve replacement.

Although bicuspid aortic valve occurs in an estimated 1% of adults and mitral valve prolapse in an estimated 5% of adults, occurrence of the 2 in the same patient is infrequent. During examination of operatively excised aortic and mitral valves because of dysfunction (stenosis and/or regurgitation), we encountered 16 patients who had congenitally bicuspid aortic valves associated with various types of dysfunctioning mitral valves. Eleven of the 16 patients had aortic stenosis (AS): 5 of them also had mitral stenosis, of rheumatic origin in 4 and secondary to mitral annular calcium in 1; the other 6 with aortic stenosis had pure mitral regurgitation (MR) secondary to mitral valve prolapse in 3, to ischemia in 2, and to unclear origin in 1. Of the 5 patients with pure aortic regurgitation, each also had pure mitral regurgitation: in 1 secondary to mitral valve prolapse and in 4 secondary to infective endocarditis. In conclusion, various types of mitral dysfunction severe enough to warrant mitral valve replacement occur in patients with bicuspid aortic valves. A proper search for mitral valve dysfunction in patients with bicuspid aortic valves appears warranted.

Aortic medial elastic fiber loss in acute ascending aortic dissection.

The cause of acute aortic dissection continues to be debated. One school of thought suggests that underlying aortic medial cystic necrosis is the common denominator. The purpose of the present study was to determine if there was loss and, if so, how much loss of medial elastic fibers in the ascending aorta in patients with acute aortic dissection with the entrance tear in the ascending aorta. We examined operatively excised ascending aortas in 69 patients having acute dissection with tears in the ascending aorta. Patients with previous aortotomy, healed dissection, and connective tissue disorders were excluded. The 69 patients' ages ranged from 31 to 88 years (mean 56); 49 were men and 20 were women. Loss of aortic medial elastic fibers was graded as 0 (no loss), 1+ (trace), 2+ (mild), 3+ (moderate), and 4+ (full thickness loss). Of these 69 patients, 56 (82%) had 0 or 1+ elastic fiber loss; 13 patients (18%), 2+ to 4+ loss including 4 with 2+, 6 with 3+, and 2 with 4+. Nearly all patients (97%) had a history of systemic hypertension and/or had received antihypertensive drug therapy. In conclusion, most patients (82% in this study) having acute aortic dissection with entrance tears in the ascending aorta have normal numbers or only trace loss of aortic medial elastic fibers. Thus, underlying abnormal ascending aortic structure uncommonly precedes acute dissection.

Effect of body mass index on survival in patients having aortic valve replacement for aortic stenosis with or without concomitant coronary artery bypass grafting.

The purpose of this report is to describe the effect of body mass index (BMI) on 30-day and late outcome in patients having aortic valve replacement (AVR) for aortic stenosis (AS) with or without concomitant coronary artery bypass grafting. From January 2002 through June 2010 (8.5 years), 1,040 operatively excised stenotic aortic valves were submitted to the cardiovascular laboratory at Baylor University Medical Center at Dallas. Of the 1,040 cases 175 were eliminated because they had a previous cardiac operation. The present study included 865 adults whose AVR for AS was their first cardiac operation. Propensity-adjusted analysis showed that 30-day and late mortality were strongly and significantly associated with BMI. Decreased risk of 30-day and long-term mortality was observed for patients with BMI in the low 30s compared to patients with BMI in the mid 20s or >40 kg/m(2). In conclusion, the findings in this study indicate a strong and significant adjusted association between BMI and 30-day and long-term mortality in patients having AVR for AS with or without concomitant coronary artery bypass grafting. Better survival was observed in patients with BMIs in the low 30s compared to patients with BMIs in the mid 20s and >40 kg/m(2).

Comparison of the structure of the aortic valve and ascending aorta in adults having aortic valve replacement for aortic stenosis versus for pure aortic regurgitation and resection of the ascending aorta for aneurysm.

BACKGROUND: There is debate concerning whether an aneurysmal ascending aorta should be replaced when associated with a dysfunctioning aortic valve that is to be replaced. To examine this issue, we divided the patients by type of aortic valve dysfunction-either aortic stenosis (AS) or pure aortic regurgitation (AR)-something not previously undertaken. METHODS AND RESULTS: Of 122 patients with ascending aortic aneurysm (unassociated with aortitis or acute dissection), the aortic valve was congenitally malformed (unicuspid or bicuspid) in 58 (98%) of the 59 AS patients, and in 38 (60%) of the 63 pure AR patients. Ascending aortic medial elastic fiber loss (EFL) (graded 0 to 4+) was zero or 1+ in 53 (90%) of the AS patients, in 20 (53%) of the 38 AR patients with bicuspid valves, and in all 12 AR patients with tricuspid valves unassociated with the Marfan syndrome. An unadjusted analysis showed that, among the 96 patients with congenitally malformed valves, the 38 AR patients had a significantly higher likelihood of 2+ to 4+ EFL than the 58 AS patients (crude odds ratio: 8.78; 95% confidence interval: 2.95, 28.13). CONCLUSIONS: These data strongly suggest that the type of aortic valve dysfunction-AS versus pure AR-is very helpful in predicting loss of aortic medial elastic fibers in patients with ascending aortic aneurysms and aortic valve disease.

Identifying cardiovascular syphilis at operation.

To describe the morphologic features so the process can be easily identified during surgery, we studied 34 patients with cardiovascular syphilis, 32 of whom underwent excision and replacement of the ascending aorta or aortic valve or both. Of the 34 patients, 22 were treated at Baylor University Medical Center from 1998 to 2008 and 12 at non-Baylor University Medical Center hospitals from 1958 to 1987. In all 34 patients, the tubular portion of the aorta was diffusely thickened and the sinus portion of the aorta was apparently uninvolved. The process involved all 3 layers of the aorta, with thickening of the adventitia, mainly by fibrous tissue. Within the fibrous tissue were collections of plasma cells and lymphocytes, focal destruction of the media without thickening, and marked thickening of the intima by atherosclerotic-appearing lesions. Serologic tests for syphilis were done in only 14 patients (41%) and were positive (reactive) in 6 (43%) of them. The ascending aorta, however, was similar in all 34 patients. In conclusion, cardiovascular syphilis has not disappeared. Its identification during surgery can prompt appropriate antibiotic therapy postoperatively. Although the serologic test results for syphilis might be negative, antibiotic therapy is recommended for patients with panaortitis requiring resection of the ascending aorta with or without aortic regurgitation.

Valve structure and survival in quinquagenarians having aortic valve replacement for aortic stenosis (+/-aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005).

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and the influence of valve structure on both early and late survival in quinquagenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). We analyzed survival and valve structure in 120 quinquagenarians having AVR for AS from 1993 through 2005 at Baylor University Medical Center, including 44 (37%) with and 76 (63%) without simultaneous CABG. Of the 120 patients, 2 (2%) died within 30 days of operation and none from 31 to 60 days postoperatively. Fifteen other patients (13%) died from >60 days to up to 13 years postoperatively. The unadjusted survival analysis showed that late survival was significantly better in the unicuspid/bicuspid valve structure group than in the tricuspid valve structure group (log-rank test p = 0.001), but that it was not affected by gender (male vs female), preoperative severity of the AS (transvalvular peak pressure gradient >50 vs < or =50 mm Hg), or by performance of CABG. The aortic valve was congenitally unicuspid in 18 patients (15%), congenitally bicuspid in 84 (70%), and 3-cuspid in 18 (15%). In conclusion, aortic valve structure affected the unadjusted late survival in quinquagenarians undergoing AVR for AS, but concomitant CABG, gender, and transvalvular peak systolic gradient had no effect.

Valve structure and survival in quadragenarians having aortic valve replacement for aortic stenosis (+/-aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005).

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and the influence of valve structure on both early and late survival in quadragenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). We analyzed survival and valve structure in 48 adults (12 women), aged 40 to 49 years, having AVR for AS from 1993 through 2005 at Baylor University Medical Center, including 7 (15%) with and 41 (85%) without simultaneous CABG. Of the 48 quadragenarians, none died within 60 days of operation. Assessment of the relation between long-term survival and gender, aortic valve structure, preoperative severity of the AS, and concomitant CABG was not possible due to the low mortality. Four patients (9%) died >60 days after AVR: at 1.8, 6.3, 7.1, and 9.9 years, respectively. The aortic valve was congenitally unicuspid in 15 patients (31%), congenitally bicuspid in 32 (67%), and 3-cuspid in 1 (2%). In conclusion, of the 48 quadragenarians having AVR for AS, 47 (98%) had a congenitally malformed aortic valve, 60-day mortality was zero, and late mortality was low (8%).

Valve structure and survival in sexagenarians having aortic valve replacement for aortic stenosis (+/-aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005).

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and the influence of valve structure on both early and late survival in sexagenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). We analyzed survival and valve structure in 289 sexagenarians having AVR for AS from 1993 through 2005 at Baylor University Medical Center, including 147 (51%) with and 142 (49%) without simultaneous CABG. Of the 282 patients with information available, 13 (4.6%) died within 30 days of operation and 1 additional patient, from 31 to 60 days after operation (5.0% 60-day mortality). Sixty-day mortality was similar (6% and 4%) in the groups with and without simultaneous CABG. A total of 66 patients (23%) died from >60 days up to 13 years postoperatively. The unadjusted survival analysis showed that late survival was not affected by gender (male versus female), aortic valve structure (unicuspid, bicuspid, and quadricuspid versus tricuspid) or preoperative severity of the AS (transvalvular peak pressure gradient >50 mm Hg versus < or =50 mm Hg), or by performance of CABG. The aortic valve was congenitally unicuspid in 10 patients (3%), congenitally bicuspid in 170 (59%), 3-cuspid in 107 (37%), congenitally quadricuspid in 1 patient, and the valve structure was indeterminate in 1 patient. In conclusion, gender, valve structure, preoperative severity of the AS, or performance of simultaneous CABG did not effect unadjusted survival in sexagenarians undergoing AVR for AS.

Valve structure and survival in septuagenarians having aortic valve replacement for aortic stenosis (+/-aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005).

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and the influence of valve structure on both early and late survival in septuagenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). We analyzed valve structure in 424 septuagenarians having AVR for AS from 1993 through 2005 at Baylor University Medical Center, including 254 (60%) with and 170 (40%) without simultaneous CABG. Of the 424 patients, 8 (2%) had a congenitally unicuspid aortic valve, 179 (42%), a congenitally bicuspid aortic valve, 235 (55%), a 3-cuspid valve, and in 2 patients (1%) the valve structure was indeterminate. Survival data were available in 418 of the 424 patients: 23 (5.5%) died within 30 days of AVR and 9 other patients from 31 to 60 days after AVR (7.7% 60-day mortality). Sixty-day mortality was not affected by congenital valve abnormality (unicuspid/bicuspid 8.5% vs tricuspid 7.0%). In contrast, late survival (up to 13-year follow-up) was affected by valve structure: it was longer in the unicuspid/bicuspid valve structure group than in the tricuspid valve structure (hazard ratio 0.54, 95% confidence intervals 0.36 to 0.81). The hazard ratio was estimated after adjusting for concomitant CABG. In conclusion, aortic valve structure affected late, but not early survival in septuagenarians undergoing AVR for AS.

Valve structure and survival in octogenarians having aortic valve replacement for aortic stenosis (+/- aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005).

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and valve structure on both early and late survival in octogenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). Although a number of reports are available in octogenarians having AVR for AS, none have described aortic valve structure. Most have limited numbers of patients and few have described late results. We analyzed survival and valve structure in 196 octogenarians having AVR for AS from 1993 to 2005 at Baylor University Medical Center, including 118 (60%) with and 78 (40%) without simultaneous CABG. Sixty-day mortality, which was identical to 30-day mortality, was similar (10% and 11%) in the groups with and without simultaneous CABG. Unadjusted analysis of late survival (up to 13 year follow-up) was not affected by gender (male vs female), aortic valve structure (bicuspid vs tricuspid) or preoperative severity of the AS (transvalvular peak pressure gradient > 50 vs < or =50 mm Hg), or by performance of CABG. Of the 196 patients, 54 (28%) had a congenitally bicuspid aortic valve, and 142 (72%) had a tricuspid aortic valve. In conclusion, gender, valve structure, preoperative severity of the AS, or performance of simultaneous CABG did not effect survival in octogenarians having AVR for AS.