• Rita Carrie Karianna Milewski, Andreas Habertheuer, Joseph E Bavaria, Maham Suhail, Mary Siki, Robert Hu, Melanie A Freas, Chirag Ram, Ananya Nanduri, Wilson Y Szeto, and Prashanth Vallabhajosyula.
• Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Conn; Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa.
• J. Thorac. Cardiovasc. Surg. 2024 Jun 1; 167 (6): 20632075.e42063-2075.e4.

ObjectiveSurgery for ascending aneurysms in bicuspid aortic valve syndrome primarily includes Bentall root replacement, aortic valve replacement with supracoronary ascending aorta replacement (AVRSCAAR), and valve-sparing root reimplantation (VSRR). Comparative analysis of long-term clinical and functional outcomes of these procedures is detailed.MethodsFrom 1997 to 2017, 635 patients with bicuspid aortic valve undergoing root complex-focused procedures electively were stratified by valvulopathy (ie, aortic stenosis vs aortic insufficiency) and substratified into ascending or root aneurysm phenotype. Inverse probability weights were calculated to adjust for baseline differences.ResultsKaplan-Meier curves for all-cause mortality demonstrated no difference between Bentall versus AVRSCAAR for aortic stenosis and aortic insufficiency presentations (log-rank P > .05). In patients with aortic stenosis, multivariable Cox regression showed significantly decreased risk of stroke for biologic AVRSCAAR (hazard ratio, 0.04; P = .013). Aortic reoperation rates were similar for biologic versus mechanical valves (P = .353). In patients with aortic insufficiency, similar long-term mortality (hazard ratio, 0.95; P = .93), but lower stroke risk in biologic AVRSCAAR group by Cox regression, and lower aortic reoperation rate was noted (coefficient < 0.01; P < .001). Comparing Bentall to VSRR, mortality (hazard ratio, 0.12; P = .022) was significantly improved in patients undergoing VSRR, but recurrence of moderate or greater aortic insufficiency was higher in VSRR by multistate model (beta coefficient 2.63; P < .001).ConclusionsA tailored approach to heterogeneous ascending aneurysm pathologies in bicuspid aortic valve syndrome utilizing Bentall, AVRSCAAR, and VSRR procedures renders excellent long-term clinical and functional outcomes, with biologic conduits showing equivalent to improved clinical outcomes.Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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