Phenotype of bicuspid aortic valve and management of the ascending aorta in 1362 patients

Objective: The management of the ascending aorta (AA) in patients with bicuspid aortic valve (BAV) undergoing valve surgery remains controversial. We analyzed our multifactorial, individualized approach to the AA during aortic valve surgery with special focus on BAV phenotypes. Methods: 1362 patients (1044 male) with surgically classified BAV undergoing valve surgery were retrospectively analyzed. Mean follow up was 5.8 ± 3.6 years (7977 patient-years). Our AA management strategy was based mainly on the diameter of the AA, age, body surface area and the perceived thickness and fragility of the aortic wall and resulted in three groups: no intervention, aortoplasty and AA replacement. Results: 33.5% of patients had AA intervention (284 replacements and 172 aortoplasties). Hospital mortality was 0.4% in the intervention group and 1.1% in the no intervention group (p = 0.2). At 10 years late survival was similar to the general population for all three groups. Reoperation rates on the AA were low (n = 4 in no intervention group, n = 1 in aortoplasty group). BAV type 2/unicuspid were younger at operation and had significantly more interventions on the AA at the same diameter. BAV type 1 LR with valve insufficiency had more frequently AA replacements. Conclusion: Individualized multifactorial decision making for the management of the AA in BAV patients during valve surgery leads to a more aggressive approach with excellent midterm results. BAV type 2/unicuspid and BAV type 1 LR with valve insufficiency may be associated with a more malignant form of AA disease and may warrant a more aggressive approach.