• Eric E Roselli, Matthew A Thompson, Farhang Yazdchi, Ashley Lowry, Douglas R Johnston, Milind Desai, Eugene H Blackstone, and Collaborators in the Cleveland Clinic Aorta and Aortic Valve Centers.
• Aorta Center, Cleveland, Ohio; Bicuspid Aortic Valve Center, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland, Ohio. Electronic address: RosellE@ccf.org.
• J. Thorac. Cardiovasc. Surg. 2024 Feb 1; 167 (2): 566577.e9566-577.e9.

ObjectivesConsensus has not been reached on whether or not to replace or preserve a well-functioning bicuspid aortic valve (BAV) in patients undergoing aortic replacement for the ascending phenotype of BAV aortopathy. We characterize morphology, evaluate progression of aortic regurgitation or aortic stenosis, and investigate the need for aortic valve replacement in patients whose well-functioning BAV was preserved during ascending aortic replacement ≥10 years prior.MethodsFrom January 1991 to August 2011, 191 patients with a well-functioning BAV underwent supracoronary aortic replacement (113 valves were minimally repaired). Aortic morphology was evaluated, aortic regurgitation grade and transvalvular aortic gradient modeled parametrically, and survival assessed by the Kaplan-Meier method. Median follow-up was 10 years.ResultsMean aortic diameter was 2.9 ± 0.53 cm at the annulus and 4.2 ± 0.55 cm at the sinuses. Mean maximum ascending diameter was 5.1 ± 0.49 cm. All patients exhibited a cusp-fusion BAV phenotype. Fifteen-year progression to severe aortic regurgitation was 3.2%. Mean aortic valve gradient began to rise 5 years postoperatively to 27 mm Hg by 14 years. Freedom from aortic valve replacement at 1, 5, 10, and 15 years was 100%, 95%, 83%, and 63%, respectively. Minimal valve repair was not associated with late aortic valve replacement. Fifteen-year survival was 74%.ConclusionsPreserving a well-functioning BAV should be considered in carefully selected patients undergoing aortic replacement for the ascending phenotype of BAV aortopathy. The valves remain durable in the long term, with slow progression of regurgitation or stenosis, and low probability of aortic valve replacement through 10 years.Copyright © 2023. Published by Elsevier Inc.

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