2023 FSA Podium and Poster Abstracts
P041: UNDIAGNOSED BICUSPID AORTIC VALVE WITH SEVERE AORTIC STENOSIS IDENTIFIED DURING A CABG
Valentina Rojas Ortiz, MD1; Jonathan Nieves2; 1HCA Florida Kendall Hospital; 2HCA Florida Westside Hospital
Introduction: Bicuspid aortic valve (BAV) is the most frequent congenital heart disease. BAV is a heterogeneous disease presenting with different phenotypes (1). It can be diagnosed in variable clinical settings such as auscultatory abnormalities or incidental echocardiographic findings, or due to early severe aortic valve dysfunction (2). Also, aortic valve stenosis secondary to bicuspid aortic valve has been incidentally found on preoperative echocardiography before an isolated coronary artery bypass graft (CABG) requiring an aortic valve replacement (AVR) in the same procedure.
Case: 80-year-old female who has been feeling short of breath for about 4 years. She recently underwent a coronary CTA and was noted to have significant coronary artery calcifications. Cardiac catheterization revealed diffuse coronary artery disease with extensive calcifications throughout and would benefit from revascularization via coronary artery bypass grafting with LIMA (left internal mammary artery) to her LAD (left anterior descending artery), SVG (Saphenous vein grafts) to OM (obtuse marginal branch of left circumflex coronary artery) and her RCA (right coronary artery). Patient was booked for a CABG. Initial transthoracic echo showed normal sized left ventricle. Systolic function was normal, and ejection fraction of 65 %. Aortic valve area (AVA) 1.3cm2, Gradient pk 36mmg Mn 22mmg. There was mild stenosis. There was mild regurgitation.
After induction, transesophageal ECHO was showed a bicuspid aortic valve Siever type 0, a valve with two symmetrical leaflets. Mean gradient 16 mmhg. Max velocity 2.5 m/s. Ascending aorta dilated max dimension 3.7 cm, 3.1 at ST junction. AVA by planimetry 1.2. Moderate left ventricular hypertrophy. As this is considered a Class I indication for AVR in patients undergoing CABG, a Bioprosthetic Aortic Valve replacement with LAA clip was performed as well.
Patient was transferred to ICU and extubated with in 6 hours.
Discussion: BAV can be diagnosed at any stage during a lifetime, from newborns to the elderly, and in the setting of variable clinical circumstances (2). Knowing about the presence of BAV before any surgery is crucial. There are several non-functional complications of BAV that are possible such as valve dysfunction, aortic dissection, and endocarditis that anesthesiologist and surgeons should be aware (3).
Severe aortic stenosis is considered a Class I indication for AVR in patients undergoing CABG. The Sievers and Schmidtke classification system are commonly use. They are simple and practical to identify all the possible BAV anatomic discrepancies and the probable consequences. Some of the functional consequences of valvulopathy includes severe stenosis and regurgitation. Sievers Type 0 consists of two leaflets without any raphes, Type 1 consists of a single raphe due to fusion of the left coronary cusp with either the right or the non-coronary cusp, and Type 2 consists of two raphes with fusion of the left coronary cusp with both the right and non-coronary (1).