Bicuspid aortic valve surgery with proactive ascending aorta repair

Objectives: Bicuspid aortic valves are associated with aortic catastrophes, particularly dissection. We examined whether proactive repair of associated dilatation would reduce risk of subsequent aortic dissection or reoperation and whether more aggressive resection is needed in patients undergoing bicuspid aortic valve surgery alone.

Methods: From January 1993 to June 2003, 1989 patients (of our total experience of 4316) underwent bicuspid aortic valve surgery. Long-term outcomes of 1810 were analyzed according to aortic size and whether bicuspid aortic valve surgery was performed alone or with aortic repair.

Results: In-hospital 30-day survival was similar (98.8% valve alone vs 98.9% with aortic repair), with no penalty incurred for concomitant aortic repair. Bicuspid aortic valve-alone patients had worse late survival (75% vs 85% at 10 years, P = .0001), but in the matched cohort survival was nearly identical (85% vs 86%; P = .7). With this strategy, freedom from late aortic events was high in both groups (99% valve alone vs 97% with aortic repair at 10 years; P[log-rank] = .06) and similar in the matched cohort (95% vs 97%; P = .2). Approximately 95% of patients undergoing valve-alone surgery had aortic diameters smaller than 4.6 cm or cross-sectional area/height ratios less than 9.4 cm(2)/m; 80% undergoing valve surgery plus aortic repair had diameters larger than 4.1 cm or ratios greater than 7.3 cm(2)/m. Only 0.2% of events occurred at an aortic diameter size of less than 4.5 cm.

Conclusions: Aortic size larger than 4.5 cm or aortic cross-sectional area/height ratio greater than 8 to 10 should be considered triggers for concurrent aortic repair, because there is no added risk, and late survival is better; however, more aggressive resection is unwarranted.