Residual root fate after aortic surgery in bicuspid aortic valve with right‐to‐left fusion: A comparative risk analysis

Abstract

Background and Aim Although bicuspid aortic valve (BAV) anatomy might influence aortic aneurysm development, BAV‐related root involvement still lacks standardized surgical management. We aimed to evaluate late clinical outcomes and risk factors for root dilation after proximal aortic replacement in patients with BAV and right–left fusion (RL‐BAV). Methods Clinical and echocardiographic data of all patients with intraoperative RL‐BAV who underwent ascending aortic replacement with or without noncoronary sinus (NCS) replacement (Groups 1 and 2, respectively) between 1999 and 2017, were retrospectively revised. A multivariable analysis assessed hazard factors for root dilation during follow‐up (FU). Results Of 206 surgeries performed (M 81%; age: 57 ± 13 years, EuroSCORE II: 2.7 ± 1.9%), 79 (38%) required NCS replacement. One hundred fifty‐seven patients (76%) underwent aortic valve replacement (with aortic regurgitation predominating in Group 1, p = .04). The preoperative aortic root was larger in patients requiring NCS replacement (43.3 ± 5.1 vs. 39.2 ± 4.8 mm, p < .001). At a median FU time of 7 years (interquartile range: 4–10), no residual root dissections occurred, and only two patients (belonging to Group 2) required redo root surgery. Preoperative mild aortic regurgitation and aortic root diameter >35 mm at discharge were risk factors for root dilation >40 mm at FU (p = .02). Aortic root did not dilate over time, irrespective of NCS replacement (p = .06). Conclusions Aortic root in patients with RL‐BAV undergoing ascending aortic replacement (±NCS replacement) does not significantly dilate over time, even if patients with preoperative aortic regurgitation and postoperative root more than 35 mm might require more surveillance.

Repair or replace the aortic root: The eternal unsolved dilemma

“…This has been previously stressed in bicuspid aortopathy, where isolated noncoronary sinus replacement can be a valid surgical alternative to David or Bentall procedures when asymmetric root dilation is present since 2007. 3 In our most recent experience, 4 patients with bicuspid aortopathy undergoing ascending aortic replacement extended to noncoronary sinus receive a significant reduction in root diameter immediately after surgery, but the residual root does not dilate over time. Despite the small number (n = 14), patients who underwent an isolated aortic replacement extended to noncoronary sinus were not at increased risk of residual root dilation, and we observed reoperation at follow-up on the native aortic valve in only 1 case.…”

Reply: Repair or replace the aortic root: The eternal unsolved dilemma

“… 4 In fact, the sinuotubular junction is not quite parallel to the aortic annulus and has a slight tilt in the right/anterior aspect. However, the left and right coronary cusps are buttressed by the coronary os, and Pradegan and colleagues 5 report increased peri-os collagen fibers (seen in the context of bicuspid aortic valve), which may protect the sinus from dilation.…”