Surgery for Aortic and Aortic Valve Pathology in Bicuspid and Tricuspid Valves Has Excellent Short- and Long-Term Outcomes: A Single-Center Experience

Objectives: Thoracic aortic aneurysm is more commonly associated with bicuspid aortic valve (BAV aortopathy) where the aortic valve is mostly stenotic. Tricuspid aortic valve–associated ascending aortic aneurysm (TAV aortopathy) is accompanied by stenotic as well as regurgitant aortic valve. We ought to determine the outcomes after combined aortic valve and ascending aorta surgery at a single institution based on valve morphology.

Methods: Between 2008 and 2018, a total of 204 patients underwent complex aortic surgery at our institution, and BAV was found in 148 (72.5%) patients. The BAV group was not significantly younger (62.2 ± 9.6 vs. 63.8 ± 9.8, < p < 0.12). More aggressive approach toward surgery in patients with smaller dimensions was taken in the BAV group. Mortality and complications were compared between these groups. Mean follow-up was 24 months.

Results: Both root and ascending aorta diameters were on average significantly smaller in BAV patients: 39.6 ± 5.6 mm, and 43.4 ± 6.3 mm for TAV root, where the ascending aorta in BAV patients was 45.7 ± 7.1 mm, and 51.6 ± 8.1 mm in TAV group (p < 0.01). Aortic valve stenosis was seen in 95.3% of BAV patients, and in 75.1% of TAV. Cardiopulmonary bypass (CPB, min) time was 148.1 ± 47.0 for the BAV group and 138.6 ± 44.9 for the TAV. Similar aortic cross-clamp time (x-clamp, min) between both groups was 109.7 ± 41.2 and 100.9 ± 39.4 for BAV and TAV, respectively. Four (2.7%) hospital deaths occurred in the BAV group and two (3.6%) in the TAV, not significantly different. In follow-up, seven (12.5%) deaths occurred in the BAV group and three (5.4%) in the TAV. Eight patients (14.3%) from the BAV group were taken for re-exploration for bleeding, with five (8.9%) from the TAV. Following surgery for BAV aortopathy, eight patients (5.4%) required permanent pacemaker against one patient (1.8%) in the TAV group. Four patients (7.1%) developed prosthesis endocarditis in the BAV group in follow-up, versus one (1.8%) in the TAV.

Conclusion: Complex aortic valve and ascending aorta surgery can be achieved in bicuspid (BAV) and tricuspid (TAV) aortopathy with low mortality and acceptable morbidity. Despite slightly younger patient collective and smaller aneurysm dimensions, the BAV aortopathy patients showed similar early mortality as the TAV, as well as required postoperative permanent pacemaker implantation at same rate as TAV aortopathy patients. Longer follow-up time should reveal if the more aggressive approach to BAV aortopathy is justified.

No conflict of interest has been declared by the author(s).