Operate NOT every BAV aorta at 5 cm Markus Schwerzmann, MD
Historical perspective Curr Probl Cardiol 2008;33:203-77 Yale Center for thoracic aortic disease database (2000): 1600 patients with a thoracic aneurysms and dissection at 6 cm risk increased 5.5 cm cut-off Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 2
Historical perspective Curr Probl Cardiol 2008;33:203-77 Yale Center for thoracic aortic disease database (2000): 1600 patients with a thoracic aneurysms and dissection 200 mmhg 100 mmhg Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 3
5.5 cm diameter an inappropriate marker of risk International Registry on Acute Aortic Dissections (3% BAV patients): diameter poor predictor, as 40% of dissection occur at diameter < 50 mm. 1 BAV patients over-represented in acute dissections registries (3-7.5% vs. 1-2% general population) BAV confers an increased risk for acute dissection, similar to genetic syndromes lower thresholds are warranted 1 Circulation, 2007. 116(10): p. 1120-7. Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 4
5.5 cm 2000 5.0 cm 4.0-5.0 cm MFS/BAV 2010 Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 5
Problems with this line of thinking Numerator / denominator problem : many BAV patients have aortic sizes 4-5 cm Survival bias: dataset includes only the ones that made it to the hospital data may not be representative Many studies and editorials challenged the recommendation to lower the thresholds for surgery. BAV is thought to be a substantially lower risk condition than Marfan syndrome. JACC Cadiovasc Imaging 2013;6:1321-6 Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 6
5.5 cm 4.5 cm 5.0 cm Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 7
It s simple, isn t it? RISK BENEFIT Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 8
Risks of replacing a dilated ascending aorta Euro-Score II: Supracoronary replacement of ascending aorta; no valve surgery; no co-morbidities, male - age 20-60 years: 1% mortality AVR and supracoronary replacement of ascending aorta (not Bentall) - age 20-60 years: 1.5% mortality David / Ross procedure - age 20-60 years: 1.5-2% mortality Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 9
Risk of AD in moderately dilated aorta 4654 non-syndromic adults with echocardiography Mean age 68 ± 13 years 1003 women 586 (12%) with bicuspid aortic valve 176 (4%) with elective ascending repair during follow-up 13 aortic dissection during 14 430 years of patients/follow-up or 0.1% per patient year J Am Coll Cardiol, 2016. 68(11): p. 1209-19 Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 10
Risk of AD in moderately dilated aorta SIZE AGE Not BAV J Am Coll Cardiol, 2016. 68(11): p. 1209-19 Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 11
Risk of AD in moderately dilated aorta 5-year risk of AD in the dilated 50 mm ascending aorta: 0.2% J Am Coll Cardiol, 2016. 68(11): p. 1209-19 Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 12
40 y. old male, BAV, diameter 5 cm BENEFIT 0.1% per 5 years RISK 1% Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 13
Risk of aortic dissection in BAV aortopathy AD in BAV aortopathy: 1 1200 BAV patients, f/u 1994-2010 5% AD (n=63) Upper treshold: 5.5 cm Lower treshold: 5.3 cm 1 Ann Thorac Surg, 2015. 100(5): 1666-74 Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 14
BAV is different from Marfan 760 patients from Australia, genetic aortopathy (incl. BAV) Age 36.9 ± 13.6 years, 26.8% female MFS: n=221; BAV: n=228 JACC 2016;67:618-26 Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 15
Risk of recurrent dissection: BAV vs. MFS 204 pts., IRAD registry, recurrent dissection Among those suffering acute AD, 5% have a history of a prior aortic dissection. Recurrent AD is strongly associated with MFS. Patients with recurrent AD were more likely to have MFS (21.5% versus 3.1%; P<0.001) but not BAV (3.6% versus 3.2%; P=0.77). Circ 2016;134:1013-24 Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 16
BAV and aortic aneurysms BAV is associated with an increased risk of aortic dilatation The risk of AD is low (0.1%) Thresholds for aortic dissection in BAV are comparable to the thresholds described for non-selected patients with ascending aortic aneurysm BAV patients have a lower risk for dissection and recurrent dissection than Marfan syndrome patients A conservative approach to surgery is appropiate for most BAV Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 17
BAV and aortic aneurysms BAV ascending aorta assessment <50 mm 50-55 mm >55 mm No risk factor Risk factors Wait and see Elective aortic replacement Do NOT operatie every aorta at 5 cm / EURO-GUCH 17 18