Bicuspid aortic valve disease and ascending aortic aneurysm: Should an aortic root replacement be mandatory?

Abstract

OBJECTIVES: The higher risk of adverse aortic events in patients with bicuspid aortic valve (BAV) disease and ascending aorta aneurysm is known, but the management of moderate aortic root dilatation in younger patients is a controversial issue. The aim of the study was to compare survival in patients with or without root replacement. METHODS: We reviewed 166 consecutive patients with BAV disease and concomitant ascending aorta aneurysm (mean ascending aorta diameter: 51.4 ± 7.2 mm) undergoing cardiac surgery from 1994 to 2010. A total of 77 patients underwent Bentall procedure (90.9% male, mean age: 55.7 ± 12.7 years, Bentall group), whereas the remaining 89 patients underwent aortic valve replacement with supracoronary ascending aorta replacement (SAAR 71.9% male, mean age: 60.5 ± 11.2 years, SAAR group, P = 0.002). The preoperative mean diameter of the root was 44.0 ± 7.2 mm in the Bentall, and 38.5 ± 4.8 mm in the SAAR group (P < 0.0001). RESULTS: In-hospital mortality was 2.6% in the Bentall, and 2.3% in the SAAR groups. Overall survival was 84 and 81% in the Bentall (median follow-up: 105 months) versus 89 and 88% in the SAAR (median follow-up: 73 months) groups at 10 and 15 years (P = 0.36), respectively. The mean cardiopulmonary bypass (CPB) time was 201 ± 56 min and 174 ± 58 min (P = 0.0016), the mean cross-clamp time 156 ± 42 min and 132 ± 38 min (P = 0.0008) in the Bentall and SAAR groups, respectively. Four sudden deaths have occurred in the Bentall group and in 2 in the SAAR group. Progressive dilatation of the aortic root in the SAAR group was not significat (postoperative mean diameter: 36.3 ± 4.4 mm). Neither subgroup of patients in the SAAR with preoperative moderate dilatation of aortic root had significat aortic dilatation at the mean follow-up of 73 ± 39 months (preoperative diameter: 43.5 ± 2.3 mm versus postoperative: 39.1 ± 4.2 mm). One patient in Bentall and 1 in the SAAR groups were reoperated for tubular graft infection. CONCLUSIONS: In patients with BAV disease, ascending aorta aneurysm and moderate dilatation of the root, the significat reduction of CPB and cross-clamp times, the stability of the residual root at long term and the low risk of adverse aortic events associated with SAAR compared with the Bentall procedure have led us to consider the isolated aortic valve replacement with supracoronary aorta replacement an alternative strategy to the Bentall procedure, especially in high-risk and older patients.