title: Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease?
abstract: OBJECTIVE
  The optimal diameter at which replacement of the ascending aorta should be performed in patients with bicuspid aortic valve disease is not known.
  
  
  METHODS
  We reviewed all patients with bicuspid aortic valves undergoing aortic valve replacement at our institution from 1979 through 1993 (n = 201). Patients undergoing concomitant replacement of the ascending aorta were excluded.
  
  
  RESULTS
  Follow-up was obtained on 98% of patients and was 10.3 +/- 3.8 (mean +/- SD) years. The average patient age was 56 +/- 15 years, and 76% were male. The ascending aorta was normal (<4.0 cm) in 115 (57%) patients, mildly dilated (4.0-4.4 cm) in 64 (32%) patients, and moderately dilated (4.5-4.9 cm) in 22 (11%) patients. All patients with bicuspid aortic valves with marked dilation (>5.0 cm) underwent replacement of the ascending aorta and were therefore excluded. Fifteen-year survival was 67%. During follow-up, 44 patients required reoperation, predominantly for aortic valve prosthesis failure. Twenty-two patients had long-term complications related to the ascending aorta: 18 required an operative procedure to replace the ascending aorta (for aortic aneurysm), 1 had aortic dissection, and 3 experienced sudden cardiac death. Fifteen-year freedom from ascending aorta-related complications was 86%, 81%, and 43% in patients with an aortic diameter of less than 4.0 cm, 4.0 to 4.4 cm, and 4.5 to 4.9 cm, respectively ( P < .001).
  
  
  CONCLUSIONS
  Patients undergoing operations for bicuspid aortic valve disease should be considered for concomitant replacement of the ascending aorta if the diameter is 4.5 cm or greater.
authors.affiliation: Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4. michael.borger@uhn.on.ca
authors.forename: Michael A
authors.initials: MA
authors.lastname: Borger
authors.forename: Mark
authors.initials: M
authors.lastname: Preston
authors.forename: Joan
authors.initials: J
authors.lastname: Ivanov
authors.forename: Paul W M
authors.initials: PW
authors.lastname: Fedak
authors.forename: Piroze
authors.initials: P
authors.lastname: Davierwala
authors.forename: Susan
authors.initials: S
authors.lastname: Armstrong
authors.forename: Tirone E
authors.initials: TE
authors.lastname: David
mesh_terms: D000368:Aged; D001011:Aorta / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000150:complications / Q000601:surgery*; D001021:Aortic Valve; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D005260:Female; D006330:Heart Defects, Congenital / Q000150:complications / Q000601:surgery*; D006349:Heart Valve Diseases / Q000150:complications / Q000151:congenital / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome