Aortic Surgery for Bicuspid Aortic Valves
- Hiratzka LF, Creager MA, Isselbacher EM, et al.
- Surgery for Aortic Dilatation in Patients With Bicuspid Aortic Valves: A Statement of Clarification From the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2015;Dec 4:[Epub ahead of print].
When should surgery be considered in asymptomatic patients with a bicuspid aortic valve and a dilated aortic root or ascending aorta?
This statement of clarification represents an update to existing guidelines. Prior guidelines had different recommendations regarding when to consider prophylactic aortic surgery for patients with a bicuspid aortic valve and a dilated aortic root or ascending aorta. This statement included representative members of two separate writing committees from prior guidelines, with a goal of achieving consensus recommendations. There are three key points to this update:
- Surgical intervention to the aortic root or ascending aorta is recommended in asymptomatic patients with a bicuspid aortic valve and an aortic root or ascending aorta ≥5.5 cm in size. This is based on Level B nonrandomized data. Overall, there are conflicting data regarding whether asymptomatic patients with bicuspid aortic valve and an aortic root or ascending aorta <5.5 cm should undergo repair.
- Surgical intervention to the aortic root or ascending aorta is reasonable in asymptomatic patients with a bicuspid aortic valve and an aortic root or ascending aorta 5.0-5.5 cm in diameter if an additional risk factor is present for aortic dissection (aortic growth ≥0.5 cm/year or family history of aortic dissection), OR if the patient is at low surgical risk and the surgery is performed by an experienced surgical team. This is based on Level B nonrandomized data. Low surgical risk is defined as a Society of Thoracic Surgeons (STS) mortality risk <4%, a lack of frailty, absence of major organ system compromise which would not improve postoperatively (e.g., fixed pulmonary hypertension or dementia), and the lack of procedure-specific impediments (e.g., radiation damage or severe calcification of ascending aorta).
- In patients with a bicuspid aortic valve planned for surgical aortic valve replacement due to severe aortic stenosis or regurgitation, it is reasonable to have a surgical intervention to the ascending aorta if the ascending aorta is >4.5 cm in size. This is based on a consensus of expert opinion, as data are limited for this statement.
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