Ascending aortic dilatation rate after transcatheter aortic valve replacement in patients with bicuspid and tricuspid aortic stenosis: A multidetector computed tomography follow-up study

doi:10.5847/wjem.j.1920-8642.2019.04.001

Abstract

Abstract:

BACKGROUND: Current data is lacking about the progression of ascending aortic dilatation after transcatheter aortic valve replacement (TAVR) in aortic stenosis (AS) patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV). This study aims to assess the ascending aortic dilatation rate (mm/year) after TAVR in patients with BAV versus TAV using a multidetector computed tomography (MDCT) follow-up and to determine the predictors of ascending aortic dilatation rate.
METHODS: Severe AS patients undergoing TAVR from March 2013 to March 2018 at our center with MDCT follow-ups were included. BAV and TAV were identified using baseline MDCT. Baseline and follow-up MDCT images were analyzed, and the diameters of ascending aorta were measured. Study end point is ascending aortic dilatation rate (mm/year). Furthermore, factors predicting ascending aortic dilatation rate were also investigated.
RESULTS: Two hundred and eight patients were included, comprised of 86 BAV and 122 TAV patients. Five, 4, 3, 2, and 1-year MDCT follow-ups were achieved in 7, 9, 30, 46, and 116 patients. The ascending aortic diameter was significantly increased after TAVR in both BAV group (43.7±4.4 mm vs. 44.0±4.5 mm; P<0.001) and TAV group (39.1±4.8 mm vs. 39.7±5.1 mm; P<0.001). However, no difference of ascending aortic dilatation rate was found between BAV and TAV groups (0.2±0.8 mm/year vs. 0.3±0.8 mm/year, P=0.592). Multivariate linear regression revealed paravalvular leakage (PVL) grade was independently associated with ascending aortic dilatation rate in the whole population and BAV group, but not TAV group. No aortic events occurred during follow-ups.
CONCLUSION: Ascending aortic size continues to grow after TAVR in BAV patients, but the dilatation rate is mild and comparable to that of TAV patients. PVL grade is associated with ascending aortic dilatation rate in BAV patients post-TAVR.

Key words: Transcatheter aortic valve replacement, Aortic dilatation, Bicuspid aortic valve

Yu-xin He, Jia-qi Fan, Qi-feng Zhu, Qi-jing Zhou, Ju-bo Jiang, Li-han Wang, Stella Ng, Xian-bao Liu, Jian-an Wang. Ascending aortic dilatation rate after transcatheter aortic valve replacement in patients with bicuspid and tricuspid aortic stenosis: A multidetector computed tomography follow-up study[J]. World Journal of Emergency Medicine, 2019, 10(4): 197-204.

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Parameters	All (n=208)	BAV (n=86)	TAV (n=122)	P value^a
Patient characteristics
Mean age (years)	76±6	76±5	77±6	0.070
Male, n (%)	129 (62.0)	44 (51.2)	85 (69.7)	0.007
BMI (kg/m²)	22.78±3.41	22.80±3.13	22.75±3.61	0.918
BSA (m²)	1.63±0.16	1.62±0.16	1.64±0.16	0.286
Bicuspid aortic valve type, n (%)
Type 0		60 (69.8)
Type 1		26 (30.2)
Type 2		0 (0.0)
Hypertension, n (%)	120 (57.7)	46 (53.5)	74 (60.7)	0.321
Diabetes mellitus, n (%)	46 (22.1)	20 (23.3)	26 (21.3)	0.865
COPD, n (%)	42 (20.2)	20 (23.3)	22 (18.0)	0.384
Atrial fibrillation, n (%)	38 (18.3)	19 (22.1)	19 (15.6)	0.275
Prior PCI, n (%)	27 (13.0)	13 (15.1)	14 (11.5)	0.531
Peripheral vascular disease, n (%)	54 (26.0)	15 (17.4)	39 (32.0)	0.024
NYHA class III or IV, n (%)	187 (89.9)	77 (89.5)	110 (90.2)	1.000
STS score (%)	6.45±4.24	5.99±3.62	6.78±4.62	0.222
Baseline TTE measurements
Aortic valve area (cm²)	0.58±0.18	0.54±0.17	0.62±0.19	0.003
Mean gradient (mmHg)	56±17	60±19	53±14	0.028
Maximal velocity (m/s)	4.83±0.72	4.97±0.78	4.73±0.66	0.021
LVEF (%)	53.8±13.0	54.4±13.6	53.4±12.6	0.418
AR, n (%)
None or trace	37 (17.8)	27 (31.4)	10 (8.2)	<0.001
Mild	95 (45.7)	48 (55.8)	47 (38.5)
Moderate or more	76 (36.5)	11 (12.8)	65 (53.3)
Ascending aorta diameter (mm)	41.0±5.1	43.7±4.4	39.1±4.8	<0.001
Ascending aorta diameter ≥45 mm, n (%)	44 (54.8)	31 (36.0)	13 (10.7)	<0.001
Procedural data, n (%)
Transfemoral access	205 (98.6)	85 (98.8)	120 (98.4)
Device
Self-expanding	170 (81.7)	75 (87.2)	95 (77.9)	0.102
Others	38 (18.3)	11 (12.8)	27 (22.1)	0.102
Pre-dilation	200 (96.2)	83 (96.5)	117 (95.9)	1.000
Post-dilation	85 (40.9)	42 (48.8)	43 (35.2)	0.063
Need for second valve implantation	17 (8.2)	6 (7.0)	11 (9.0)	0.621

Parameters	All (n=208)	BAV (n=86)	TAV (n=122)	P value^a
Follow-up period (years)	1.8±1.1	1.7±1.1	1.8±1.1	0.182
5-year follow-up, n (%)	7 (3.4)	3 (3.5)	4 (3.3)	0.317
4-year follow-up, n (%)	9 (4.3)	4 (4.6)	5 (4.1)
3-year follow-up, n (%)	30 (14.4)	9 (10.5)	21 (17.2)
2-year follow-up, n (%)	46 (22.1)	17 (19.8)	29 (23.8)
1-year follow-up, n (%)	116 (55.8)	53 (61.6)	63 (51.6)
Ascending aorta diameter at follow-ups (mm)	41.5±5.3	44.0±4.5	39.7±5.1	<0.001
Change of ascending aorta diameter at follow-ups (mm)	0.5±1.0	0.4±0.9	0.6±1.1	0.238
Ascending aortic dilatation rate (mm/year)	0.3±0.8	0.2±0.8	0.3±0.8	0.592
TTE measurements at follow-ups
Aortic valve area (cm²)	1.57±0.35	1.51±0.33	1.61±0.36	0.115
Mean gradient (mmHg)	11±6	101±45	11±7	0.635
Maximal velocity (m/s)	2.25±0.55	2.27±0.46	2.24±0.61	0.650
LVEF (%)	62.5±8.7	64.5±5.9	61.0±10.0	0.028
PVL, n (%)
None or trace	105 (50.5)	43 (50.0)	62 (50.8)	0.924
Mild	84 (40.4)	36 (41.9)	48 (39.3)
Moderate or more	19 (9.1)	7 (8.1)	12 (9.8)

Predictors	Univariate regression			Multivariate regression
Predictors	Coefficients (β)	Standard error of β	P value	Coefficients (β)	Standard error of β	P value
Age, years	-0.022	0.015	0.136	-0.018	0.014	0.211
Male	0.130	0.161	0.419
BMI (kg/m²)	0.014	0.026	0.599
BSA (m²)	0.296	0.501	0.557
Hypertension	0.219	0.160	0.174	0.278	0.148	0.065
Diabetes	-0.011	0.191	0.955
Baseline ascending aortic diameter (mm)	0.020	0.018	0.279
Self-expanding valve	0.124	0.241	0.607
Years of follow-up (years)	-0.019	0.076	0.799
Baseline TTE measurements
Mean gradient (mmHg)	-0.008	0.004	0.042	-0.007	0.014	0.614
Maximal velocity (m/s)	-0.206	0.101	0.045	0.019	0.342	0.956
Aortic valve area (cm²)	0.637	0.471	0.180	-0.195	0.513	0.705
LVEF (%)	-0.006	0.006	0.336
AR 0-2	0.014	0.126	0.911
Follow-up TTE measurements
Mean gradient (mmHg)	0.004	0.018	0.802
Maximal velocity (m/s)	-0.036	0.178	0.840
Aortic valve area (cm²)	0.176	0.250	0.482
LVEF (%)	-0.019	0.014	0.164	-0.011	0.013	0.399
PVL 0-2	0.482	0.115	<0.001	0.495	0.117	<0.001

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