title: Effect of aortic aneurysm replacement on outcomes after bicuspid aortic valve surgery: validation of contemporary guidelines.
abstract: OBJECTIVE
  Bicuspid aortic valve (BAV) disease is associated with aortic dilatation and aneurysm (AN) formation. The American College of Cardiology/American Heart Association (ACC/AHA) 2006 guidelines recommend replacement of the ascending aorta for an aortic diameter (AD)> 45 mm in patients undergoing aortic valve replacement (AVR). We evaluated the outcomes of AVR and AVR with aortic replacement (AVR/AN).
  
  
  METHODS
  We retrospectively reviewed (2004-2011) the data from 456 patients with BAV and compared the morbidity and mortality between the AVR and AVR/AN groups and 3 subgroups: AVR with an AD<45 mm; AVR/AN with an AD of 45 to 49 mm; and AVR/AN with an AD of ≥50 mm. Propensity score matching was used to reduce bias.
  
  
  RESULTS
  Of the 456 patients, 250 (55%) underwent AVR and 206 (45%) AVR/AN, with 98% compliance with the current guidelines. The overall 30-day mortality was 0.9%. The AVR AD<45-mm group had adjusted short- and medium-term survival similar to that of the AVR/AN AD 45- to 49-mm and AVR/AN AD≥50-mm groups, with a 30-day mortality of 0.8%, 0%, and 1.9%, respectively (P=.41). The propensity score-matched AVR/AN AD≥50-mm group had significantly greater rates of reintubation than either the AVR AD<45-mm (P=.012) or AVR/AN AD 45- to 49-mm (P=.04) group and greater rates of prolonged ventilation (P=.022) than the AVR AD<45-mm group. No significant differences were found in reoperation or myocardial infarction among the subgroups.
  
  
  CONCLUSIONS
  In patients with undergoing AVR, no increase was seen in morbidity or mortality when adding aortic replacement with an AD of 45 to 49 mm, in accordance with the 2006 ACC/AHA guidelines, although the AVR/AN AD≥50-mm group had a greater risk of respiratory complications. Our findings indicate that compliance with the ACC/AHA guidelines is safe in select centers.
authors.affiliation: Division of Cardiac Surgery, Martha and Richard Melman Family Bicuspid Aortic Valve Program, Bluhm Cardiovascular Institute, Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Ill.
authors.forename: Daniel
authors.initials: D
authors.lastname: Rinewalt
authors.affiliation: Division of Cardiac Surgery, Martha and Richard Melman Family Bicuspid Aortic Valve Program, Bluhm Cardiovascular Institute, Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Ill. Electronic address: pmccart@nmh.org.
authors.forename: Patrick M
authors.initials: PM
authors.lastname: McCarthy
authors.affiliation: Division of Cardiac Surgery, Martha and Richard Melman Family Bicuspid Aortic Valve Program, Bluhm Cardiovascular Institute, Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Ill.
authors.forename: Sukit Chris
authors.initials: SC
authors.lastname: Malaisrie
authors.affiliation: Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Paul W M
authors.initials: PW
authors.lastname: Fedak
authors.affiliation: Division of Cardiac Surgery, Martha and Richard Melman Family Bicuspid Aortic Valve Program, Bluhm Cardiovascular Institute, Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Ill.
authors.forename: Adin-Cristian
authors.initials: AC
authors.lastname: Andrei
authors.affiliation: Division of Cardiology, Martha and Richard Melman Family Bicuspid Aortic Valve Program, Bluhm Cardiovascular Institute, Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Ill.
authors.forename: Jyothy J
authors.initials: JJ
authors.lastname: Puthumana
authors.affiliation: Division of Cardiology, Martha and Richard Melman Family Bicuspid Aortic Valve Program, Bluhm Cardiovascular Institute, Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Ill.
authors.forename: Robert O
authors.initials: RO
authors.lastname: Bonow
mesh_terms: D000328:Adult; D000368:Aged; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D001021:Aortic Valve / Q000002:abnormalities* / Q000601:surgery; D000082882:Bicuspid Aortic Valve Disease; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality / Q000592:standards*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000592:standards*; D016009:Chi-Square Distribution; D005260:Female; D019983:Guideline Adherence / Q000592:standards*; D006349:Heart Valve Diseases / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D017410:Practice Guidelines as Topic / Q000592:standards*; D057216:Propensity Score; D016016:Proportional Hazards Models; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome