Fate of Un-replaced Sinuses of Valsalva in Bicuspid Aortic Valve Disease: Follow-up to 17 years Chan Park 1, Hector Michelena 2, Thoralf M. Sundt 1 Divisions.

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Fate of Un-replaced Sinuses of Valsalva in Bicuspid Aortic Valve Disease: Follow-up to 17 years Chan Park 1, Hector Michelena 2, Thoralf M. Sundt 1 Divisions of Cardiovascular Surgery 1 and Cardiovascular Medicine 2 Mayo Clinic Rochester, Minnesota

Patient Characteristics Age (yrs) 62±13 Male (%) 75.2 F/U period (yrs) 0-17(3.3) Diabetes mellitus (%) 10.1 Hypercholesterolemia (%) 60.6 Renal failure (%) 2.3 NYHA III/IV (%) 39.0 Coronary artery disease (%) 30.7

Operative Results ACC (min) 68.8±28.9 CPB (min) 96.0±43.7 Circulatory arrest (min) 18.5±13.2 Type of Valve (Mech:Bio) 109:109 Procedures NCC procedure NCC procedure 15 (6.9%) Ascending aortoplasty Ascending aortoplasty 65 (29.8%) Ascending graft Ascending graft 153 (70.2%) Arch surgery Arch surgery 13 (6.0%)

Preoperative Echo finding Dominance Stenosis (%) Stenosis (%)69.6 Insufficiency (%) Insufficiency (%)24.9 Mixed (%) Mixed (%)5.5 EF (%) 59.5±11.7 Size (mm) Annulus Annulus25.7±4.6 Sinus Sinus40.4±5.7 STJ STJ 34.6± ±5.3 Ascending aorta Ascending aorta 50.6±6.8

Outcomes Operative mortality: 2.8% Overall mortality: 28/218 (12.8%) Cause of death Cardiac 5/28 (17.9%) Non-cardiac 11/28 (39.3%) Unknown 12/28 (42.9%)

Reoperation Reoperation: 10/218 (4.6%) Indication Aortic root dilation (1) Ascending aorta dilatation (2) PVE (3) PVE (3) PPM (2) PPM (2) Others (4) Others (4)

Se x Ag e Interval (yrs) Primary operation Reason for reoperationReoperation M4913.2AortoplastyPPMAVR+CABG M710.3AscAoRpPVEAVR M679.2 Aortoplasty+ CABG Aortic Root and AscAo dilatation Graft replaceof AoRoot & AscAo M651.5AortoplastyRCA aneurysmCABG M409.0AortoplastyPPM & AscAo dilatationAVR+AscAo replace M653.8AortoplastyPVE Homograft replacement of AoRoot & CABG M750.9AscAoRpMediastinitis Valveless Homograft AscAo replacement M750.3AscAoRpPVE Homograft replacement of AoRoot M600.1 TotalArch+Prox Desc+CABG Thoracoabdominal aneurysm Thoracoabdominal aorta replacement M631.3 AscAoRp+PFO closure Periprosthetic leakage Repair of periprosthetic leakage Details for Reoperations

Survival Freedom from Reoperation Probability (%) Follow-up (years) 1 year probability: 97.6% 5 year probabilitiy: 94.9% 10 year probability: 85.5%

Univariate Analysis for Overall Survival HR p value Age DM4.99<0.001 Preop renal failure NYHA (III/IV) CAD3.62<0.001 Bioprosthetic valve

Multivariate Analysis for Overall Survival HR p value Age DM5.32<0.001 Preop renal failure NYHA (III/IV)

Change of Aortic Size at 5 years (n= 28) AnnulusSinusSTJAscAo Size (mm) * * † * p<0.05 preop vs postop, † p<0.001 preop vs postop

Conclusions The sinuses of Valsalva rarely dilate significantly after AVR and aortic repairThe sinuses of Valsalva rarely dilate significantly after AVR and aortic repair Separate valve and graft remains a reasonable option in the absence of significant root dilatationSeparate valve and graft remains a reasonable option in the absence of significant root dilatation The ascending aorta remains at risk of late dilatation if treated with aortoplastyThe ascending aorta remains at risk of late dilatation if treated with aortoplasty