José Navia - Academia.edu (original) (raw)

Papers by José Navia

Research paper thumbnail of Abstract 13370: Long-term Outcomes of Patients with Pseudoaneurysms and a History of Prior Cardiovascular Surgery

Circulation, 2014

Background: Data regarding long-term outcomes in patients with cardiovascular (CV) pseudoaneurysm... more Background: Data regarding long-term outcomes in patients with cardiovascular (CV) pseudoaneurysms (PSA) is sparse. In patients with prior CV surgery, we sought to assess outcomes in patients with PSAs (defined as paravalvular, aortic root, or ascending aorta PSAs) & compare them with matched controls. Methods: As part of a cohort study (total n=342), we included 114 patients with prior CV surgery who presented with paravalvular (n=71, 59 at the aortic valve & 12 at the mitral valve) & ascending aortic (n=43) PSAs. A control group of patients (n=228) with prior CV surgery, matched in a 2:1 fashion based on age, gender, type & time of CV surgery, were also included. Standard clinical, echocardiographic & surgical data was collected & Euroscore was calculated. A composite endpoint of death & stroke during follow-up were recorded. Results: Baseline data are shown in Figure A. 80% of patients in each group underwent redo CV surgery during follow-up. Over a follow-up of 6.7±4 years, ther...

Research paper thumbnail of Right versus left heart reverse remodelling after treating ischaemic mitral and tricuspid regurgitation

European Journal of Cardio-Thoracic Surgery, 2020

OBJECTIVESRepair outcomes of tricuspid regurgitation (TR) associated with ischaemic mitral regurg... more OBJECTIVESRepair outcomes of tricuspid regurgitation (TR) associated with ischaemic mitral regurgitation (IMR) are inferior to functional TR in terms of TR recurrence and right ventricular (RV) reverse remodelling. Our objective is to analyse right versus left heart reverse remodelling after surgery for IMR-associated TR.METHODSFrom 2001 to 2011, 568 patients with severe IMR underwent mitral valve surgery (repair 87%, replacement 13%), and 131 had concomitant tricuspid valve repair. Median follow-up was 3.0 years; 25% of living patients were followed up for 6.3 years. Longitudinal analysis of 1527 follow-up echocardiograms was performed to assess ventricular reverse remodelling and function.RESULTSUnlike the left heart, the right heart failed to reverse remodel (failed to recover ventricular function or halt dilatation). During follow-up after surgery, the right ventricle continued to dilate while the left ventricle regressed in size. RV ejection fraction decreased (46% at 1 month a...

Research paper thumbnail of Transcatheter Tricuspid Valve Implantation of NaviGate Bioprosthesis in a Preclinical Model

JACC: Basic to Translational Science, 2018

HIGHLIGHTS Surgery for isolated tricuspid regurgitation carries a high mortality risk, especially... more HIGHLIGHTS Surgery for isolated tricuspid regurgitation carries a high mortality risk, especially in the setting of right ventricular dysfunction and reoperation. Transcatheter valve therapy is as promising alternative for treatment of isolated tricuspid valve disease associated with right heart failure. The NaviGate bioprosthesis is a novel self-expanding valved stent designed to treat functional tricuspid regurgitation. The preclinical evaluation shows that transcatheter tricuspid valve implantation using the NaviGate device is safe, is feasible through 2 different approaches, and results in a secure and stable engagement of the native annulus, with excellent hemodynamic and valve performance.

Research paper thumbnail of Characteristics and longer-term outcomes of paravalvular leak after aortic and mitral valve surgery

The Journal of Thoracic and Cardiovascular Surgery, 2018

Background: Paravalvular leak (PVL) is often seen after aortic (AV) and mitral valve (MV) surgery... more Background: Paravalvular leak (PVL) is often seen after aortic (AV) and mitral valve (MV) surgery, either due to infection or valve dehiscence. We sought to describe predictors of longer-term outcomes in patients who developed PVL after AV and MV surgery and were considered eligible for reoperative cardiac surgery (RCS). Methods: We studied 495 such patients (65 AE 14 years, 65% men, 47% with MV PVL) who presented at our center between January 2003 and December 2011. Patients with severe mitral/aortic stenosis, patients with less than mild PVL, and those with prohibitive risk precluding RCS were excluded. Society of Thoracic Surgeons (STS) score was calculated. Primary endpoint was mortality. Results: At baseline, mean STS score and left ventricular ejection fraction were 5.8 AE 4% and 52 AE 12%, respectively. In total, 105 (21%) had infective PVL and 72% had moderate or greater PVL. At a median of 8 days, 351 (71%) patients underwent RCS to repair PVL (3% in-hospital postoperative mortality), and at 6.6 AE 4 years, 230 (47%) patients died. On multivariable Cox survival analysis, greater STS score (hazard ratio or HR 1.35), mitral versus aortic PVL (HR 1.66), infectious etiology (HR 2.05), and greater right ventricular systolic pressure (HR 1.09) were associated with greater longer-term mortality, whereas surgery (HR 0.58) was associated with improved longer-term survival (all P <.05). Conclusions: Patients who develop mild or greater PVL after AV/MV surgery have a high rate of longer-term mortality, despite excellent perioperative outcomes. Greater STS score, right ventricular systolic pressure, infectious etiology, and MV (vs AV) involvement were all independently associated with long-term mortality, whereas RCS for PVL closure was associated with improved longerterm survival.

Research paper thumbnail of Pseudo-vanishing lung syndrome in a patient with tricuspid valve bacterial endocarditis

Journal of cardiology cases, 2018

Infective endocarditis is a major cause of morbidity and mortality among individuals with opioid ... more Infective endocarditis is a major cause of morbidity and mortality among individuals with opioid use disorder who use injection drugs. It is frequently associated with tricuspid valve endocarditis and bacteremia, with secondary pulmonary septic emboli. Herein, we report a unique case of pulmonary cavitation injury following pulmonary septic emboli in the setting of tricuspid valve endocarditis in an injection drug user with opioid use disorder. The pattern of cavitary lung injury mimics radiographically indistinguishable features from vanishing lung syndrome during the most advanced stage of her illness. < This manuscript aims to highlight a new complication of bacterial endocarditis secondary to septic emboli showered from the infected tricuspid valve. This complication, which resembles a pulmonary disease by the name of vanishing lung syndrome, is characterized by extensive pneumatoceles that give the appearance of vanishing lung on chest radiography.>.

Research paper thumbnail of The incorporated aortomitral homograft for double-valve endocarditis: the 'hemi-Commando' procedure. Early and mid-term outcomes

European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, May 15, 2017

Surgical management of invasive double-valve infective endocarditis (IE) involving the intervalvu... more Surgical management of invasive double-valve infective endocarditis (IE) involving the intervalvular fibrosa (IVF) is a technical challenge that requires extensive debridement followed by complex reconstruction. In this study, we present the early and mid-term outcomes of the hemi-Commando procedure and aortic root replacement with reconstruction of IVF using an aortomitral allograft. From 2010 to 2017, 37 patients with IE involving the IVF underwent the hemi-Commando procedure. Postoperative clinical data and echocardiograms were reviewed for the assessment of cardiac structural integrity and clinical outcomes. Twenty-nine (78%) cases were redo surgery and 15 (41%) were emergency surgery. Preoperatively, 70% (n = 26) of patients were admitted to the intensive care unit and 11% (n = 4) of patients were in septic shock. Ten (27%) patients had native aortic valve IE, while 27 (73%) patients had prosthetic valve IE. Hospital death occurred in 8% (n = 3) of patients due to multisystem o...

Research paper thumbnail of Rarity of invasiveness in right-sided infective endocarditis

The Journal of Thoracic and Cardiovascular Surgery, 2017

Objective: The rarity of invasiveness of right-sided infective endocarditis (IE) compared with le... more Objective: The rarity of invasiveness of right-sided infective endocarditis (IE) compared with left-sided has not been well recognized and evaluated. Thus, we compared invasiveness of right-versus left-sided IE in surgically treated patients.

Research paper thumbnail of Early results of robotically assisted mitral valve surgery: Analysis of the first 1000 cases

The Journal of Thoracic and Cardiovascular Surgery, 2017

Objective: The study objective was to assess the technical and process improvement and clinical o... more Objective: The study objective was to assess the technical and process improvement and clinical outcomes of robotic mitral valve surgery by examining the first 1000 cases performed in a tertiary care center. Methods: We reviewed the first 1000 patients (mean age, 56 AE 10 years) undergoing robotic primary mitral valve surgery, including concomitant procedures (n ¼ 185), from January 2006 to November 2013. Mitral valve disease cause was degenerative (n ¼ 960, 96%), endocarditis (n ¼ 26, 2.6%), rheumatic (n ¼ 10, 1.0%), ischemic (n ¼ 3, 0.3%), and fibroelastoma (n ¼ 1, 0.1%). All procedures were performed via right chest access with femoral perfusion for cardiopulmonary bypass. Results: Mitral valve repair was attempted in 997 patients (2 planned replacements and 1 resection of fibroelastoma), 992 (99.5%) of whom underwent valve repair, and 5 (0.5%) of whom underwent valve replacement. Intraoperative postrepair echocardiography showed that 99.7% of patients receiving repair (989/ 992) left the operating room with no or mild mitral regurgitation, and predischarge echocardiography showed that mitral regurgitation remained mild or less in 97.9% of patients (915/935). There was 1 hospital death (0.1%), and 14 patients (1.4%) experienced a stroke; stroke risk declined from 2% in the first 500 patients to 0.8% in the second 500 patients. Over the course of the experience, myocardial ischemic and cardiopulmonary bypass times (P<.0001), transfusion (P ¼ .003), and intensive care unit and postoperative lengths of stay (P <.05) decreased. Conclusions: Robotic mitral valve surgery is associated with a high likelihood of valve repair and low operative mortality and morbidity. The combination of algorithm-driven patient selection and increased experience enhanced clinical outcomes and procedural efficiency.

Research paper thumbnail of Value of surgery for infective endocarditis in dialysis patients

The Journal of Thoracic and Cardiovascular Surgery, 2017

Objectives: To determine the value of surgery for infective endocarditis (IE) in patients on hemo... more Objectives: To determine the value of surgery for infective endocarditis (IE) in patients on hemodialysis by comparing the nature and invasiveness of endocarditis in hemodialysis and nonhemodialysis patients and their hospital and long-term outcomes, and identifying risk factors for time-related mortality after surgery. Methods: From January 1997 to January 2013, 144 patients on chronic hemodialysis and 1233 nonhemodialysis patients underwent valve surgery for IE at our institution. Propensity matching identified 99 well-matched hemodialysis and nonhemodialysis patient pairs for comparison of outcomes. Results: Staphylococcus aureus infection was more common in hemodialysis patients than in nonhemodialysis patients (42% vs 21%; P <.0001), but invasive disease was similar in the 2 groups (47%; P ¼ .3). Hospital mortality was 13% and 5-year survival was 20% for hemodialysis patients, 20% below that expected in a general hemodialysis population but 15% above that of hemodialysis patients treated nonsurgically for IE. For matched patients, hospital mortality was 13% for hemodialysis patients versus 5.1% for nonhemodialysis patients (P ¼ .05), and survival at 1 and 5 years was 56% versus 83% and 24% versus 59%, respectively (P < .004). Use of an arteriovenous graft for dialysis access (P ¼ .01) and preoperative placement of a pacemaker (P < .0001) were risk factors for late mortality in hemodialysis patients. For matched patients, freedom from reoperation was similar in the hemodialysis and nonhemodialysis groups (P >.9). Conclusions: Intermediate-term survival after surgery for IE in hemodialysis patients is substantially worse than that in nonhemodialysis patients, but only slightly worse than that in the general hemodialysis population and substantially better than that in hemodialysis patients with IE treated nonsurgically, supporting continued surgical intervention for IE. (

Research paper thumbnail of Valve Repair Is Superior to Replacement in Most Patients With Coexisting Degenerative Mitral Valve and Coronary Artery Diseases

The Annals of thoracic surgery, Jan 6, 2016

For mitral regurgitation (MR) from degenerative mitral disease in patients with coexisting corona... more For mitral regurgitation (MR) from degenerative mitral disease in patients with coexisting coronary artery disease, the appropriate surgical strategy remains controversial. From 1985 to 2011, 1,071 adults (age 70 ± 9.3 years, 77% men) underwent combined coronary artery bypass grafting and either mitral valve repair (n = 872, 81%) or replacement (n=199, 19%) for degenerative MR. Propensity matching (177 patient pairs, 89% of possible matches) was used to compare early outcomes and time-related recurrence of MR after mitral valve repair, mitral valve reoperation, and mortality. Risk factors for death were identified with multivariable, multiphase hazard-function analysis. Patients undergoing valve replacement were older, with more valve calcification and a higher prevalence of preoperative atrial fibrillation and heart failure (all p < .0001). Among matched pairs, mitral replacement versus repair was associated with higher hospital mortality (5.0% vs 1.0%, p = .0001) and more posto...

Research paper thumbnail of Long-term survival, valve durability, and reoperation for 4 aortic root procedures combined with ascending aorta replacement

The Journal of Thoracic and Cardiovascular Surgery, 2016

Objective: To evaluate long-term results of aortic root procedures combined with ascending aorta ... more Objective: To evaluate long-term results of aortic root procedures combined with ascending aorta replacement for aneurysms, using 4 surgical strategies. Methods: From January 1995 to January 2011, 957 patients underwent 1 of 4 aortic root procedures: valve preservation (remodeling or modified reimplantation, n ¼ 261); composite biologic graft (n ¼ 297); composite mechanical graft (n ¼ 156); or allograft root (n ¼ 243). Results: Seven deaths occurred (0.73%), none after valve-preserving procedures, and 13 strokes (1.4%). Composite grafts exhibited higher gradients than allografts or valve preservation, but the latter 2 exhibited more aortic regurgitation (2.7% biologic and 0% mechanical composite grafts vs 24% valve-preserving and 19% allografts at 10 years). Within 2 to 5 years, valve preservation exhibited the least left ventricular hypertrophy, allograft replacement the greatest; however, valve preservation had the highest early risk of reoperation, allograft replacement the lowest. Patients receiving allografts had the highest risk of late reoperation (P<.05), and those receiving composite mechanical grafts and valve preservation had the lowest. Composite bioprosthesis patients had the highest risk of late death (57% at 15 years vs 14%-26% for the remaining procedures, P<.0001), because they were substantially older and had more comorbidities (P <.0001). Conclusions: These 4 aortic root procedures, combined with ascending aorta replacement, provide excellent survival and good durability. Valve-preserving and allograft procedures have the lowest gradients and best ventricular remodeling, but they have more late regurgitation, and likely, less risk of valve-related complications, such as bleeding, hemorrhage, and endocarditis. Despite the early risk of reoperation, we recommend valve-preserving procedures for young patients when possible. Composite bioprostheses are preferable for the elderly.

Research paper thumbnail of Complications and Intensity of Care of Community-based Parenteral Anti-infective Therapy for Patients with Cardiac Infections

Background: Community-based parenteral anti-infective therapy (CoPAT) is a treatment option for s... more Background: Community-based parenteral anti-infective therapy (CoPAT) is a treatment option for selected patients with cardiac (endocarditis and cardiac device) infections. This study examines the intensity of care and associated complications of such therapy. Methods: At the Cleveland Clinic, all pts requiring CoPAT are evaluated and managed by infectious disease (ID) physicians. Pts with cardiac infections discharged between July 1, 2007 and June 30, 2008 were identified from our CoPAT registry. Complications (vascular access issues and antibiotic adverse effects) and intensity of care (hospital readmissions, emergency department [ED] visits, office visits and telephone encounters) were evaluated for 30 days after completion of IV antibiotics or till readmission. Results: One hundred and ninety-seven pts received 216 CoPAT courses for cardiac infections (68 native valve endocarditis, 53 prosthetic valve endocarditis, and 95 pacemaker/ICD infections; with 28, 19, and 5, respectivel...

Research paper thumbnail of Renal cell carcinoma with extensive cavoatrial involvement

The Journal of heart valve disease, 2013

Research paper thumbnail of Long-term Outcomes of Patients with Pseudoaneurysms and a History of Prior Cardiovascular Surgery

Research paper thumbnail of Risk factors and impact on outcome Duration of inotropic support after left ventricular assist device implantation

Research paper thumbnail of Duration of inotropic support after left ventricular assist device implantation: Risk factors and impact on outcome

The Journal of Thoracic and Cardiovascular Surgery, 2006

Objectives: Because duration of inotropic support after left ventricular assist device implantati... more Objectives: Because duration of inotropic support after left ventricular assist device implantation has been recognized as a surrogate for right ventricular dysfunction, we sought to (1) identify its preimplantation risk factors, particularly its association with preimplantation right ventricular dysfunction, and (2) assess its impact on clinical outcomes. Methods: Between 1991 and 2002, left ventricular assist devices were implanted in 207 patients, exclusive of those receiving preoperative mechanical circulatory support, which precluded measuring right ventricular stroke work. Duration of inotropic support was analyzed as a continuous variable, truncated by death or transplantation, and in turn as a risk factor for these 2 events. Results: Inotropic support decreased from 100% on the day of implantation to 57%, 33%, and 22% by days 7, 14, and 21. Its duration was strongly associated with lower preimplantation right ventricular stroke work index, older age, and nonischemic cardiomyopathy and was associated (P Ͻ .04) with higher mortality before transplantation but not with transition to transplantation. We identified no preimplantation risk factors for right ventricular assist device use because of its relatively infrequent use in this population (18 patients, only 4 of whom survived to transplantation). Conclusion: Duration of inotropic support after left ventricular assist device insertion is strongly correlated with low preimplantation right ventricular stroke work index. In turn, it was associated with reduced survival to transplantation. Thus, right ventricular stroke work measured before implantation might be useful in decision making for biventricular support, destination therapy, or total artificial heart.

Research paper thumbnail of Does successful bridging with the implantable left ventricular assist device affect cardiac transplantation outcome?

The Journal of Thoracic and Cardiovascular Surgery, 1996

We sought to determine whether cardiac transplant recipients who required a bridge to transplanta... more We sought to determine whether cardiac transplant recipients who required a bridge to transplantation with an implantable left ventricular assist device had a different outcome than patients who underwent transplantation without such a bridge. Methods: A retrospective study of 256 cardiac transplants from 1992 to 1996 included 53 patients who received the HeartMate left ventricular assist device and 203 patients who had no left ventricular assist device support. Results: Left ventricular assist device transplants increased from 8% of all transplants in 1992 (n = 63) to 32% in 1995 (n = 65) and 43% in 1996 (n = 14 year to date). Patients with and without left ventricular assist device had similar age and sex distributions. Left ventricular assist device recipients were larger (body surface area 1.96 vs 1.86 m 2, p = 0.004). They were more likely to have ischemic cardiomyopathy (70% vs 45%, p = 0.001) and type O blood group (51% vs 34%, p = 0.06). All patients with left ventricular assist device and 42% of those without had undergone previous cardiac operations by the time of transplantation (mean number per patient 1.5 vs 0.3, p < 0.001). More patients in the left ventricular assist device group had anti-HLA antibodies before transplantation (T-cell panel reactive antibody level > 10% in 66% of left ventricular assist device group vs 15% of control group, p < 0.0001). Waiting time was longer for the left ventricular assist device than for patients in status I without a left ventricular assist device (median 88 vs 37 days, p = 0.002). There was no difference in length of posttransplantation hospital stay (median 15 days for each) or operative mortality (3.8% vs 4.4%). Mean follow-up averaged 22 months. No significant difference was found in Kaplan-Meier survival estimates. One-year survival was 94% in the left ventricular assist device group and 88% in the control group (difference not significant). Comparison of posttransplantation events showed no significant difference in actuarial rates of cytomegalovirus infection (20% vs 17%) or vascular rejection (15% vs 12%) at 1 year of follow-up. Similar percentages of patients were free from cellular rejection at 1 year of follow-up (12% vs 22%, p = 0.36). Conclusions: Left ventricular assist device support intensified the donor shortage by including recipients who otherwise would not have survived to transplantation. Bridging affected transplant demographics, favoring patients who are larger, have ischemic cardiomyopathy, have had multiple blood

Research paper thumbnail of The Cox maze procedure in mitral valve disease: Predictors of recurrent atrial fibrillation

The Journal of Thoracic and Cardiovascular Surgery, 2005

Objectives: The Cox maze procedure is the gold standard for ablation of atrial fibrillation in pa... more Objectives: The Cox maze procedure is the gold standard for ablation of atrial fibrillation in patients undergoing mitral valve surgery, and new approaches to atrial fibrillation ablation must be compared with it. Therefore, we sought to determine the time-related prevalence of atrial fibrillation and its risk factors after combined Cox maze and mitral valve surgery. Methods: From November 1991 through January 2004, 263 patients (mean left atrial diameter, 5.8 Ϯ 1.2 cm) underwent combined mitral valve surgery (repair in 71%) and a cut-and-sew Cox maze procedure for atrial fibrillation (permanent, 74%; persistent, 7%; paroxysmal, 16%). Rhythm documented on 2367 postoperative electrocardiograms was used to estimate the prevalence of atrial fibrillation across time. Results: Hospital mortality was 1.9%. Postoperative atrial fibrillation prevalence peaked at 36% at 2 weeks, decreasing to 21% at 5 years. Risk factors for higher postoperative atrial fibrillation prevalence varied with time and included longer duration of preoperative atrial fibrillation (P ϭ .003), larger left atrial diameter (P ϭ .01), older age (P ϭ .0002), and higher left ventricular mass index (P ϭ .02). Conclusions: In some patients undergoing mitral valve surgery and a Cox maze procedure, atrial fibrillation recurs over time, mandating close, long-term follow-up of heart rhythm. Earlier operation and left atrial size reduction should be considered to improve results in selected patients.

Research paper thumbnail of Should less-invasive aortic valve replacement be avoided in patients with pulmonary dysfunction?

The Journal of Thoracic and Cardiovascular Surgery, 2014

In patients with pulmonary dysfunction, it is unclear whether a less-invasive approach for aortic... more In patients with pulmonary dysfunction, it is unclear whether a less-invasive approach for aortic valve replacement is well tolerated or even beneficial. We investigated whether a partial upper J-incision for aortic valve replacement leads to more favorable outcomes than a full sternotomy in patients with chronic lung disease by using forced expiratory volume in 1 second as a surrogate. Methods: From January 1995 to July 2010, 6931 patients underwent primary isolated aortic valve replacement; 655 had forced expiratory volume in 1 second measured and expressed as percent of predicted (FEV1%; 368 via J-incision, 287 via full sternotomy). Postoperative outcomes were compared among 223 propensity-matched pairs. Results: Patients diagnosed with chronic lung disease had longer median intensive care unit (41 vs 27 hours, P ¼ .001) and postoperative (7.1 vs 6.1 days, P<.0001) lengths of stay than those without chronic lung disease. At normal values of FEV1%, little difference was observed in either of these times for J-incision versus full sternotomy; however, at progressively lower FEV1%, these times lengthened, with increasing benefit for J-incision. Among propensity-matched patients, other postoperative complications were similar. Early survival (93% vs 89% at 1 year, P ¼ .07) was possibly higher in matched patients with J-incision, but late survival was similar (P ¼ .9). Patients with FEV1% less than 50 who underwent J-incision had the greatest survival advantage, which persisted for 5 years. Conclusions: In patients with preoperative respiratory dysfunction, a less-invasive partial upper J-incision for aortic valve replacement can lead to more favorable outcomes than a full sternotomy, including shorter intensive care unit and postoperative lengths of stay and better early survival, which are amplified with decreasing pulmonary function.

Research paper thumbnail of Aortic Dissection in Patients with Bicuspid Aortic Valves: Clinical and Pathologic Comparison with Tricuspid Valves

Journal of the American College of Cardiology, 2013

Background: Bicuspid aortic valve (BAV) is common and associated with a higher risk of aortic dis... more Background: Bicuspid aortic valve (BAV) is common and associated with a higher risk of aortic dissection (AD) compared to the predominantly tricuspid aortic valve (TAV) general population. The differences between BAV and TAV patients presenting with AD are unknown. methods: We retrospectively analyzed clinical characteristics, aortic imaging, and pathologic findings of all patients with confirmed BAV and AD from 1980-2010. Characteristics were compared to a consecutive TAV control group with AD. results: Of 47 BAV patients (mean age 58±14, 77% male), 31(66%) had acute AD, 16(34%) chronic AD, 40(85%) had typical BAV, 32(68%) had hypertension and 11(23%) had previous aortic coarctation. Of 53 TAV patients (mean age 66±13[p=0.007], 76% male), 34(66%) had acute AD (p=1.0) and 46(87%) had hypertension (p=0.03). More BAV patients had known aortic dilatation prior to AD (49% vs.17%, p=0.001). Symptoms at presentation were no different between groups (all p=NS). Maximal ascending aortic diameter at AD was higher in the BAV group compared with TAV group (66±15mm vs. 56±11mm, p = 0.0004). Previous aortic valve replacement was more common in BAV (23% vs 6%, p=0.02). Of 11 BAV patients with previous isolated aortic valve replacement, 7 had ≥moderate ascending aorta dilatation at the time of surgery. BAV patients had increased aortic jet velocity (40% vs. 9%) and more severe aortic stenosis (19% vs. 0%) at presentation compared to TAV patients (p=0.0004 and 0.0007). In patients presenting with acute AD, aortic medial degeneration was found in 75% of BAV aortic specimens, versus 41% of TAV specimens (p=0.01). Conversely, aortic atherosclerosis was more frequent in TAV patients (56% vs. 26%, p=0.02) with acute AD. conclusions: BAV patients presenting with AD are younger, have a lower prevalence of hypertension, higher prevalence of previous coarctation, higher prevalence of previous valve replacement and valve stenosis, higher maximal aortic dimension, and worse aortic medial degeneration, compared with TAV patients. AD could have been prevented by elective aorta repair in 7 out of 11 BAV patients with previous valve replacement and moderate aortic dilatation. CORE Metadata, citation and similar papers at core.ac.uk

Research paper thumbnail of Abstract 13370: Long-term Outcomes of Patients with Pseudoaneurysms and a History of Prior Cardiovascular Surgery

Circulation, 2014

Background: Data regarding long-term outcomes in patients with cardiovascular (CV) pseudoaneurysm... more Background: Data regarding long-term outcomes in patients with cardiovascular (CV) pseudoaneurysms (PSA) is sparse. In patients with prior CV surgery, we sought to assess outcomes in patients with PSAs (defined as paravalvular, aortic root, or ascending aorta PSAs) & compare them with matched controls. Methods: As part of a cohort study (total n=342), we included 114 patients with prior CV surgery who presented with paravalvular (n=71, 59 at the aortic valve & 12 at the mitral valve) & ascending aortic (n=43) PSAs. A control group of patients (n=228) with prior CV surgery, matched in a 2:1 fashion based on age, gender, type & time of CV surgery, were also included. Standard clinical, echocardiographic & surgical data was collected & Euroscore was calculated. A composite endpoint of death & stroke during follow-up were recorded. Results: Baseline data are shown in Figure A. 80% of patients in each group underwent redo CV surgery during follow-up. Over a follow-up of 6.7±4 years, ther...

Research paper thumbnail of Right versus left heart reverse remodelling after treating ischaemic mitral and tricuspid regurgitation

European Journal of Cardio-Thoracic Surgery, 2020

OBJECTIVESRepair outcomes of tricuspid regurgitation (TR) associated with ischaemic mitral regurg... more OBJECTIVESRepair outcomes of tricuspid regurgitation (TR) associated with ischaemic mitral regurgitation (IMR) are inferior to functional TR in terms of TR recurrence and right ventricular (RV) reverse remodelling. Our objective is to analyse right versus left heart reverse remodelling after surgery for IMR-associated TR.METHODSFrom 2001 to 2011, 568 patients with severe IMR underwent mitral valve surgery (repair 87%, replacement 13%), and 131 had concomitant tricuspid valve repair. Median follow-up was 3.0 years; 25% of living patients were followed up for 6.3 years. Longitudinal analysis of 1527 follow-up echocardiograms was performed to assess ventricular reverse remodelling and function.RESULTSUnlike the left heart, the right heart failed to reverse remodel (failed to recover ventricular function or halt dilatation). During follow-up after surgery, the right ventricle continued to dilate while the left ventricle regressed in size. RV ejection fraction decreased (46% at 1 month a...

Research paper thumbnail of Transcatheter Tricuspid Valve Implantation of NaviGate Bioprosthesis in a Preclinical Model

JACC: Basic to Translational Science, 2018

HIGHLIGHTS Surgery for isolated tricuspid regurgitation carries a high mortality risk, especially... more HIGHLIGHTS Surgery for isolated tricuspid regurgitation carries a high mortality risk, especially in the setting of right ventricular dysfunction and reoperation. Transcatheter valve therapy is as promising alternative for treatment of isolated tricuspid valve disease associated with right heart failure. The NaviGate bioprosthesis is a novel self-expanding valved stent designed to treat functional tricuspid regurgitation. The preclinical evaluation shows that transcatheter tricuspid valve implantation using the NaviGate device is safe, is feasible through 2 different approaches, and results in a secure and stable engagement of the native annulus, with excellent hemodynamic and valve performance.

Research paper thumbnail of Characteristics and longer-term outcomes of paravalvular leak after aortic and mitral valve surgery

The Journal of Thoracic and Cardiovascular Surgery, 2018

Background: Paravalvular leak (PVL) is often seen after aortic (AV) and mitral valve (MV) surgery... more Background: Paravalvular leak (PVL) is often seen after aortic (AV) and mitral valve (MV) surgery, either due to infection or valve dehiscence. We sought to describe predictors of longer-term outcomes in patients who developed PVL after AV and MV surgery and were considered eligible for reoperative cardiac surgery (RCS). Methods: We studied 495 such patients (65 AE 14 years, 65% men, 47% with MV PVL) who presented at our center between January 2003 and December 2011. Patients with severe mitral/aortic stenosis, patients with less than mild PVL, and those with prohibitive risk precluding RCS were excluded. Society of Thoracic Surgeons (STS) score was calculated. Primary endpoint was mortality. Results: At baseline, mean STS score and left ventricular ejection fraction were 5.8 AE 4% and 52 AE 12%, respectively. In total, 105 (21%) had infective PVL and 72% had moderate or greater PVL. At a median of 8 days, 351 (71%) patients underwent RCS to repair PVL (3% in-hospital postoperative mortality), and at 6.6 AE 4 years, 230 (47%) patients died. On multivariable Cox survival analysis, greater STS score (hazard ratio or HR 1.35), mitral versus aortic PVL (HR 1.66), infectious etiology (HR 2.05), and greater right ventricular systolic pressure (HR 1.09) were associated with greater longer-term mortality, whereas surgery (HR 0.58) was associated with improved longer-term survival (all P <.05). Conclusions: Patients who develop mild or greater PVL after AV/MV surgery have a high rate of longer-term mortality, despite excellent perioperative outcomes. Greater STS score, right ventricular systolic pressure, infectious etiology, and MV (vs AV) involvement were all independently associated with long-term mortality, whereas RCS for PVL closure was associated with improved longerterm survival.

Research paper thumbnail of Pseudo-vanishing lung syndrome in a patient with tricuspid valve bacterial endocarditis

Journal of cardiology cases, 2018

Infective endocarditis is a major cause of morbidity and mortality among individuals with opioid ... more Infective endocarditis is a major cause of morbidity and mortality among individuals with opioid use disorder who use injection drugs. It is frequently associated with tricuspid valve endocarditis and bacteremia, with secondary pulmonary septic emboli. Herein, we report a unique case of pulmonary cavitation injury following pulmonary septic emboli in the setting of tricuspid valve endocarditis in an injection drug user with opioid use disorder. The pattern of cavitary lung injury mimics radiographically indistinguishable features from vanishing lung syndrome during the most advanced stage of her illness. < This manuscript aims to highlight a new complication of bacterial endocarditis secondary to septic emboli showered from the infected tricuspid valve. This complication, which resembles a pulmonary disease by the name of vanishing lung syndrome, is characterized by extensive pneumatoceles that give the appearance of vanishing lung on chest radiography.>.

Research paper thumbnail of The incorporated aortomitral homograft for double-valve endocarditis: the 'hemi-Commando' procedure. Early and mid-term outcomes

European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, May 15, 2017

Surgical management of invasive double-valve infective endocarditis (IE) involving the intervalvu... more Surgical management of invasive double-valve infective endocarditis (IE) involving the intervalvular fibrosa (IVF) is a technical challenge that requires extensive debridement followed by complex reconstruction. In this study, we present the early and mid-term outcomes of the hemi-Commando procedure and aortic root replacement with reconstruction of IVF using an aortomitral allograft. From 2010 to 2017, 37 patients with IE involving the IVF underwent the hemi-Commando procedure. Postoperative clinical data and echocardiograms were reviewed for the assessment of cardiac structural integrity and clinical outcomes. Twenty-nine (78%) cases were redo surgery and 15 (41%) were emergency surgery. Preoperatively, 70% (n = 26) of patients were admitted to the intensive care unit and 11% (n = 4) of patients were in septic shock. Ten (27%) patients had native aortic valve IE, while 27 (73%) patients had prosthetic valve IE. Hospital death occurred in 8% (n = 3) of patients due to multisystem o...

Research paper thumbnail of Rarity of invasiveness in right-sided infective endocarditis

The Journal of Thoracic and Cardiovascular Surgery, 2017

Objective: The rarity of invasiveness of right-sided infective endocarditis (IE) compared with le... more Objective: The rarity of invasiveness of right-sided infective endocarditis (IE) compared with left-sided has not been well recognized and evaluated. Thus, we compared invasiveness of right-versus left-sided IE in surgically treated patients.

Research paper thumbnail of Early results of robotically assisted mitral valve surgery: Analysis of the first 1000 cases

The Journal of Thoracic and Cardiovascular Surgery, 2017

Objective: The study objective was to assess the technical and process improvement and clinical o... more Objective: The study objective was to assess the technical and process improvement and clinical outcomes of robotic mitral valve surgery by examining the first 1000 cases performed in a tertiary care center. Methods: We reviewed the first 1000 patients (mean age, 56 AE 10 years) undergoing robotic primary mitral valve surgery, including concomitant procedures (n ¼ 185), from January 2006 to November 2013. Mitral valve disease cause was degenerative (n ¼ 960, 96%), endocarditis (n ¼ 26, 2.6%), rheumatic (n ¼ 10, 1.0%), ischemic (n ¼ 3, 0.3%), and fibroelastoma (n ¼ 1, 0.1%). All procedures were performed via right chest access with femoral perfusion for cardiopulmonary bypass. Results: Mitral valve repair was attempted in 997 patients (2 planned replacements and 1 resection of fibroelastoma), 992 (99.5%) of whom underwent valve repair, and 5 (0.5%) of whom underwent valve replacement. Intraoperative postrepair echocardiography showed that 99.7% of patients receiving repair (989/ 992) left the operating room with no or mild mitral regurgitation, and predischarge echocardiography showed that mitral regurgitation remained mild or less in 97.9% of patients (915/935). There was 1 hospital death (0.1%), and 14 patients (1.4%) experienced a stroke; stroke risk declined from 2% in the first 500 patients to 0.8% in the second 500 patients. Over the course of the experience, myocardial ischemic and cardiopulmonary bypass times (P<.0001), transfusion (P ¼ .003), and intensive care unit and postoperative lengths of stay (P <.05) decreased. Conclusions: Robotic mitral valve surgery is associated with a high likelihood of valve repair and low operative mortality and morbidity. The combination of algorithm-driven patient selection and increased experience enhanced clinical outcomes and procedural efficiency.

Research paper thumbnail of Value of surgery for infective endocarditis in dialysis patients

The Journal of Thoracic and Cardiovascular Surgery, 2017

Objectives: To determine the value of surgery for infective endocarditis (IE) in patients on hemo... more Objectives: To determine the value of surgery for infective endocarditis (IE) in patients on hemodialysis by comparing the nature and invasiveness of endocarditis in hemodialysis and nonhemodialysis patients and their hospital and long-term outcomes, and identifying risk factors for time-related mortality after surgery. Methods: From January 1997 to January 2013, 144 patients on chronic hemodialysis and 1233 nonhemodialysis patients underwent valve surgery for IE at our institution. Propensity matching identified 99 well-matched hemodialysis and nonhemodialysis patient pairs for comparison of outcomes. Results: Staphylococcus aureus infection was more common in hemodialysis patients than in nonhemodialysis patients (42% vs 21%; P <.0001), but invasive disease was similar in the 2 groups (47%; P ¼ .3). Hospital mortality was 13% and 5-year survival was 20% for hemodialysis patients, 20% below that expected in a general hemodialysis population but 15% above that of hemodialysis patients treated nonsurgically for IE. For matched patients, hospital mortality was 13% for hemodialysis patients versus 5.1% for nonhemodialysis patients (P ¼ .05), and survival at 1 and 5 years was 56% versus 83% and 24% versus 59%, respectively (P < .004). Use of an arteriovenous graft for dialysis access (P ¼ .01) and preoperative placement of a pacemaker (P < .0001) were risk factors for late mortality in hemodialysis patients. For matched patients, freedom from reoperation was similar in the hemodialysis and nonhemodialysis groups (P >.9). Conclusions: Intermediate-term survival after surgery for IE in hemodialysis patients is substantially worse than that in nonhemodialysis patients, but only slightly worse than that in the general hemodialysis population and substantially better than that in hemodialysis patients with IE treated nonsurgically, supporting continued surgical intervention for IE. (

Research paper thumbnail of Valve Repair Is Superior to Replacement in Most Patients With Coexisting Degenerative Mitral Valve and Coronary Artery Diseases

The Annals of thoracic surgery, Jan 6, 2016

For mitral regurgitation (MR) from degenerative mitral disease in patients with coexisting corona... more For mitral regurgitation (MR) from degenerative mitral disease in patients with coexisting coronary artery disease, the appropriate surgical strategy remains controversial. From 1985 to 2011, 1,071 adults (age 70 ± 9.3 years, 77% men) underwent combined coronary artery bypass grafting and either mitral valve repair (n = 872, 81%) or replacement (n=199, 19%) for degenerative MR. Propensity matching (177 patient pairs, 89% of possible matches) was used to compare early outcomes and time-related recurrence of MR after mitral valve repair, mitral valve reoperation, and mortality. Risk factors for death were identified with multivariable, multiphase hazard-function analysis. Patients undergoing valve replacement were older, with more valve calcification and a higher prevalence of preoperative atrial fibrillation and heart failure (all p < .0001). Among matched pairs, mitral replacement versus repair was associated with higher hospital mortality (5.0% vs 1.0%, p = .0001) and more posto...

Research paper thumbnail of Long-term survival, valve durability, and reoperation for 4 aortic root procedures combined with ascending aorta replacement

The Journal of Thoracic and Cardiovascular Surgery, 2016

Objective: To evaluate long-term results of aortic root procedures combined with ascending aorta ... more Objective: To evaluate long-term results of aortic root procedures combined with ascending aorta replacement for aneurysms, using 4 surgical strategies. Methods: From January 1995 to January 2011, 957 patients underwent 1 of 4 aortic root procedures: valve preservation (remodeling or modified reimplantation, n ¼ 261); composite biologic graft (n ¼ 297); composite mechanical graft (n ¼ 156); or allograft root (n ¼ 243). Results: Seven deaths occurred (0.73%), none after valve-preserving procedures, and 13 strokes (1.4%). Composite grafts exhibited higher gradients than allografts or valve preservation, but the latter 2 exhibited more aortic regurgitation (2.7% biologic and 0% mechanical composite grafts vs 24% valve-preserving and 19% allografts at 10 years). Within 2 to 5 years, valve preservation exhibited the least left ventricular hypertrophy, allograft replacement the greatest; however, valve preservation had the highest early risk of reoperation, allograft replacement the lowest. Patients receiving allografts had the highest risk of late reoperation (P<.05), and those receiving composite mechanical grafts and valve preservation had the lowest. Composite bioprosthesis patients had the highest risk of late death (57% at 15 years vs 14%-26% for the remaining procedures, P<.0001), because they were substantially older and had more comorbidities (P <.0001). Conclusions: These 4 aortic root procedures, combined with ascending aorta replacement, provide excellent survival and good durability. Valve-preserving and allograft procedures have the lowest gradients and best ventricular remodeling, but they have more late regurgitation, and likely, less risk of valve-related complications, such as bleeding, hemorrhage, and endocarditis. Despite the early risk of reoperation, we recommend valve-preserving procedures for young patients when possible. Composite bioprostheses are preferable for the elderly.

Research paper thumbnail of Complications and Intensity of Care of Community-based Parenteral Anti-infective Therapy for Patients with Cardiac Infections

Background: Community-based parenteral anti-infective therapy (CoPAT) is a treatment option for s... more Background: Community-based parenteral anti-infective therapy (CoPAT) is a treatment option for selected patients with cardiac (endocarditis and cardiac device) infections. This study examines the intensity of care and associated complications of such therapy. Methods: At the Cleveland Clinic, all pts requiring CoPAT are evaluated and managed by infectious disease (ID) physicians. Pts with cardiac infections discharged between July 1, 2007 and June 30, 2008 were identified from our CoPAT registry. Complications (vascular access issues and antibiotic adverse effects) and intensity of care (hospital readmissions, emergency department [ED] visits, office visits and telephone encounters) were evaluated for 30 days after completion of IV antibiotics or till readmission. Results: One hundred and ninety-seven pts received 216 CoPAT courses for cardiac infections (68 native valve endocarditis, 53 prosthetic valve endocarditis, and 95 pacemaker/ICD infections; with 28, 19, and 5, respectivel...

Research paper thumbnail of Renal cell carcinoma with extensive cavoatrial involvement

The Journal of heart valve disease, 2013

Research paper thumbnail of Long-term Outcomes of Patients with Pseudoaneurysms and a History of Prior Cardiovascular Surgery

Research paper thumbnail of Risk factors and impact on outcome Duration of inotropic support after left ventricular assist device implantation

Research paper thumbnail of Duration of inotropic support after left ventricular assist device implantation: Risk factors and impact on outcome

The Journal of Thoracic and Cardiovascular Surgery, 2006

Objectives: Because duration of inotropic support after left ventricular assist device implantati... more Objectives: Because duration of inotropic support after left ventricular assist device implantation has been recognized as a surrogate for right ventricular dysfunction, we sought to (1) identify its preimplantation risk factors, particularly its association with preimplantation right ventricular dysfunction, and (2) assess its impact on clinical outcomes. Methods: Between 1991 and 2002, left ventricular assist devices were implanted in 207 patients, exclusive of those receiving preoperative mechanical circulatory support, which precluded measuring right ventricular stroke work. Duration of inotropic support was analyzed as a continuous variable, truncated by death or transplantation, and in turn as a risk factor for these 2 events. Results: Inotropic support decreased from 100% on the day of implantation to 57%, 33%, and 22% by days 7, 14, and 21. Its duration was strongly associated with lower preimplantation right ventricular stroke work index, older age, and nonischemic cardiomyopathy and was associated (P Ͻ .04) with higher mortality before transplantation but not with transition to transplantation. We identified no preimplantation risk factors for right ventricular assist device use because of its relatively infrequent use in this population (18 patients, only 4 of whom survived to transplantation). Conclusion: Duration of inotropic support after left ventricular assist device insertion is strongly correlated with low preimplantation right ventricular stroke work index. In turn, it was associated with reduced survival to transplantation. Thus, right ventricular stroke work measured before implantation might be useful in decision making for biventricular support, destination therapy, or total artificial heart.

Research paper thumbnail of Does successful bridging with the implantable left ventricular assist device affect cardiac transplantation outcome?

The Journal of Thoracic and Cardiovascular Surgery, 1996

We sought to determine whether cardiac transplant recipients who required a bridge to transplanta... more We sought to determine whether cardiac transplant recipients who required a bridge to transplantation with an implantable left ventricular assist device had a different outcome than patients who underwent transplantation without such a bridge. Methods: A retrospective study of 256 cardiac transplants from 1992 to 1996 included 53 patients who received the HeartMate left ventricular assist device and 203 patients who had no left ventricular assist device support. Results: Left ventricular assist device transplants increased from 8% of all transplants in 1992 (n = 63) to 32% in 1995 (n = 65) and 43% in 1996 (n = 14 year to date). Patients with and without left ventricular assist device had similar age and sex distributions. Left ventricular assist device recipients were larger (body surface area 1.96 vs 1.86 m 2, p = 0.004). They were more likely to have ischemic cardiomyopathy (70% vs 45%, p = 0.001) and type O blood group (51% vs 34%, p = 0.06). All patients with left ventricular assist device and 42% of those without had undergone previous cardiac operations by the time of transplantation (mean number per patient 1.5 vs 0.3, p < 0.001). More patients in the left ventricular assist device group had anti-HLA antibodies before transplantation (T-cell panel reactive antibody level > 10% in 66% of left ventricular assist device group vs 15% of control group, p < 0.0001). Waiting time was longer for the left ventricular assist device than for patients in status I without a left ventricular assist device (median 88 vs 37 days, p = 0.002). There was no difference in length of posttransplantation hospital stay (median 15 days for each) or operative mortality (3.8% vs 4.4%). Mean follow-up averaged 22 months. No significant difference was found in Kaplan-Meier survival estimates. One-year survival was 94% in the left ventricular assist device group and 88% in the control group (difference not significant). Comparison of posttransplantation events showed no significant difference in actuarial rates of cytomegalovirus infection (20% vs 17%) or vascular rejection (15% vs 12%) at 1 year of follow-up. Similar percentages of patients were free from cellular rejection at 1 year of follow-up (12% vs 22%, p = 0.36). Conclusions: Left ventricular assist device support intensified the donor shortage by including recipients who otherwise would not have survived to transplantation. Bridging affected transplant demographics, favoring patients who are larger, have ischemic cardiomyopathy, have had multiple blood

Research paper thumbnail of The Cox maze procedure in mitral valve disease: Predictors of recurrent atrial fibrillation

The Journal of Thoracic and Cardiovascular Surgery, 2005

Objectives: The Cox maze procedure is the gold standard for ablation of atrial fibrillation in pa... more Objectives: The Cox maze procedure is the gold standard for ablation of atrial fibrillation in patients undergoing mitral valve surgery, and new approaches to atrial fibrillation ablation must be compared with it. Therefore, we sought to determine the time-related prevalence of atrial fibrillation and its risk factors after combined Cox maze and mitral valve surgery. Methods: From November 1991 through January 2004, 263 patients (mean left atrial diameter, 5.8 Ϯ 1.2 cm) underwent combined mitral valve surgery (repair in 71%) and a cut-and-sew Cox maze procedure for atrial fibrillation (permanent, 74%; persistent, 7%; paroxysmal, 16%). Rhythm documented on 2367 postoperative electrocardiograms was used to estimate the prevalence of atrial fibrillation across time. Results: Hospital mortality was 1.9%. Postoperative atrial fibrillation prevalence peaked at 36% at 2 weeks, decreasing to 21% at 5 years. Risk factors for higher postoperative atrial fibrillation prevalence varied with time and included longer duration of preoperative atrial fibrillation (P ϭ .003), larger left atrial diameter (P ϭ .01), older age (P ϭ .0002), and higher left ventricular mass index (P ϭ .02). Conclusions: In some patients undergoing mitral valve surgery and a Cox maze procedure, atrial fibrillation recurs over time, mandating close, long-term follow-up of heart rhythm. Earlier operation and left atrial size reduction should be considered to improve results in selected patients.

Research paper thumbnail of Should less-invasive aortic valve replacement be avoided in patients with pulmonary dysfunction?

The Journal of Thoracic and Cardiovascular Surgery, 2014

In patients with pulmonary dysfunction, it is unclear whether a less-invasive approach for aortic... more In patients with pulmonary dysfunction, it is unclear whether a less-invasive approach for aortic valve replacement is well tolerated or even beneficial. We investigated whether a partial upper J-incision for aortic valve replacement leads to more favorable outcomes than a full sternotomy in patients with chronic lung disease by using forced expiratory volume in 1 second as a surrogate. Methods: From January 1995 to July 2010, 6931 patients underwent primary isolated aortic valve replacement; 655 had forced expiratory volume in 1 second measured and expressed as percent of predicted (FEV1%; 368 via J-incision, 287 via full sternotomy). Postoperative outcomes were compared among 223 propensity-matched pairs. Results: Patients diagnosed with chronic lung disease had longer median intensive care unit (41 vs 27 hours, P ¼ .001) and postoperative (7.1 vs 6.1 days, P<.0001) lengths of stay than those without chronic lung disease. At normal values of FEV1%, little difference was observed in either of these times for J-incision versus full sternotomy; however, at progressively lower FEV1%, these times lengthened, with increasing benefit for J-incision. Among propensity-matched patients, other postoperative complications were similar. Early survival (93% vs 89% at 1 year, P ¼ .07) was possibly higher in matched patients with J-incision, but late survival was similar (P ¼ .9). Patients with FEV1% less than 50 who underwent J-incision had the greatest survival advantage, which persisted for 5 years. Conclusions: In patients with preoperative respiratory dysfunction, a less-invasive partial upper J-incision for aortic valve replacement can lead to more favorable outcomes than a full sternotomy, including shorter intensive care unit and postoperative lengths of stay and better early survival, which are amplified with decreasing pulmonary function.

Research paper thumbnail of Aortic Dissection in Patients with Bicuspid Aortic Valves: Clinical and Pathologic Comparison with Tricuspid Valves

Journal of the American College of Cardiology, 2013

Background: Bicuspid aortic valve (BAV) is common and associated with a higher risk of aortic dis... more Background: Bicuspid aortic valve (BAV) is common and associated with a higher risk of aortic dissection (AD) compared to the predominantly tricuspid aortic valve (TAV) general population. The differences between BAV and TAV patients presenting with AD are unknown. methods: We retrospectively analyzed clinical characteristics, aortic imaging, and pathologic findings of all patients with confirmed BAV and AD from 1980-2010. Characteristics were compared to a consecutive TAV control group with AD. results: Of 47 BAV patients (mean age 58±14, 77% male), 31(66%) had acute AD, 16(34%) chronic AD, 40(85%) had typical BAV, 32(68%) had hypertension and 11(23%) had previous aortic coarctation. Of 53 TAV patients (mean age 66±13[p=0.007], 76% male), 34(66%) had acute AD (p=1.0) and 46(87%) had hypertension (p=0.03). More BAV patients had known aortic dilatation prior to AD (49% vs.17%, p=0.001). Symptoms at presentation were no different between groups (all p=NS). Maximal ascending aortic diameter at AD was higher in the BAV group compared with TAV group (66±15mm vs. 56±11mm, p = 0.0004). Previous aortic valve replacement was more common in BAV (23% vs 6%, p=0.02). Of 11 BAV patients with previous isolated aortic valve replacement, 7 had ≥moderate ascending aorta dilatation at the time of surgery. BAV patients had increased aortic jet velocity (40% vs. 9%) and more severe aortic stenosis (19% vs. 0%) at presentation compared to TAV patients (p=0.0004 and 0.0007). In patients presenting with acute AD, aortic medial degeneration was found in 75% of BAV aortic specimens, versus 41% of TAV specimens (p=0.01). Conversely, aortic atherosclerosis was more frequent in TAV patients (56% vs. 26%, p=0.02) with acute AD. conclusions: BAV patients presenting with AD are younger, have a lower prevalence of hypertension, higher prevalence of previous coarctation, higher prevalence of previous valve replacement and valve stenosis, higher maximal aortic dimension, and worse aortic medial degeneration, compared with TAV patients. AD could have been prevented by elective aorta repair in 7 out of 11 BAV patients with previous valve replacement and moderate aortic dilatation. CORE Metadata, citation and similar papers at core.ac.uk