Objective

Bicuspid aortic valve disease (BAV) is associated with aortic root dilation (RD), increasing the risk of adverse aortic root events. Current guidelines recommend concomitant root replacement (ARR) in patients undergoing aortic valve replacement (AVR) when the root diameter (ARD) is ≥45mm. However, ARR is believed to increase surgical risk. We reviewed current practice of surgery for BAV at our centre and compared long-term outcomes of AVR, either isolated or with ARR.

Methods

Our in-hospital database was explored for patients who were treated for congenital BAV between 2004 and 2015. Patients with concomitant replacement of the ascending aorta and coronary artery bypass grafting (CABG) were left in the group, concomitant non-aortic heart valve procedures and patients with functional BAV were excluded. The remaining 242 patients were divided according to the treatment received, into patients receiving ARR (n=59) or isolated AVR (n=183).

Results

ARR patients were younger (p<0.01) but had a higher logistic EuroSCORE (p<0.01). Mean ARD was 39.5 ±7.1mm in ARR vs. 34.5 ±5.4mm in AVR (p<0.01). In AVR, 32.2% of patients had an ARD≥40mm (n=59). Procedural times were longer in ARR (p<0.01). Stroke occurred in 1.7% (n=1, ARR) and 2.2% (n=4, AVR, p=1.0). In ARR, survival at 30 days was 100% vs. 99.5% in AVR (p=1.0). Survival at 5 years was 91.7% vs. 82.9% (p=0.88). During follow-up, 3.4% (n=2) after AVR needed repeat surgery for increased ARD.

Conclusion

Our experience shows, that one-third of patients receiving AVR for BAV is not treated according to current guidelines. Re-operations in this group were due to pre-existent RD. However, ARR does not increase perioperative risk and therefore we recommend ARR as the appropriate treatment in patients with pre-existent RD.