title: When to operate on the bicuspid valve patient with a modestly dilated ascending aorta.
abstract: BACKGROUND
  Bicuspid aortic valves (BAV) are frequently associated with root/ascending aorta dilatation, but there is controversy regarding when to operate to prevent dissection of a dilated aorta associated with a well-functioning BAV.
  
  
  METHODS
  From 1988 through 2008, 158 patients (mean age: 56 ± 13.5 years) with a dilated ascending aorta (AA) and a well-functioning BAV were referred to our institution. All patients underwent computed tomographic (CT) scanning and digitization to calculate mean AA diameter. Forty-two patients underwent operation a median of 52 days after initial CT scan with a mean AA diameter of 5.6 ± 0.5 cm. One hundred sixteen patients (mean diameter 4.6 ± 0.5 cm) were enrolled in annual or semiannual surveillance. Seventy-one patients, 45 with 2 or more CT scans, are still under surveillance.
  
  
  RESULTS
  Average follow-up was 6.5 ± 4.1 years. Overall survival after the first encounter was 93% at 5 years and 85% at 10 years. A total of 87 of 158 patients had a Bentall or Yacoub procedure, with two hospital deaths (2.3%). Mean duration of surveillance in the 116 patients without immediate operation was 4.2 ± 2.9 years (481 patient-years). Average growth rate of the AA in patients with 2 scans or greater was 0.77 mm/year (p < 0.0001 versus normal population) with no significant impact of hypertension, sex, smoking or age. Forty-five of the 116 surveillance patients underwent operation after a mean of 3.4 ± 2.9 years (mean age 55 ± 14.7 years; mean AA diameter 4.9 ± 0.6 cm). Six patients died without surgery, median age 82 (range, 44 to 87) years, but none within one year of the last CT scan.
  
  
  CONCLUSIONS
  A consistent approach to patients with a well-functioning BAV and AA dilatation, recommending operation to those with an AA diameter greater than 5 cm and deferring operation in patients under surveillance in the absence of significant enlargement (>0.5 cm/year), resulted in overall survival equivalent to a normal age-matched and sex-matched population. Operation was necessary in approximately 10% of patients under surveillance each year.
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York 10029, USA. christian.etz@mountsinai.org
authors.forename: Christian D
authors.initials: CD
authors.lastname: Etz
authors.forename: Stefano
authors.initials: S
authors.lastname: Zoli
authors.forename: Robert
authors.initials: R
authors.lastname: Brenner
authors.forename: Fabian
authors.initials: F
authors.lastname: Roder
authors.forename: Moritz
authors.initials: M
authors.lastname: Bischoff
authors.forename: Carol A
authors.initials: CA
authors.lastname: Bodian
authors.forename: Gabriele
authors.initials: G
authors.lastname: DiLuozzo
authors.forename: Randall B
authors.initials: RB
authors.lastname: Griepp
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D001018:Aortic Diseases / Q000175:diagnosis* / Q000209:etiology / Q000601:surgery; D001021:Aortic Valve / Q000002:abnormalities* / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D003657:Decision Making; D004108:Dilatation, Pathologic; D005260:Female; D005500:Follow-Up Studies; D006349:Heart Valve Diseases / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D014057:Tomography, X-Ray Computed