title: Surgical threshold for bicuspid aortic valve aneurysm: a case for individual decision-making.
abstract: The bicuspid aortic valve (BAV) affects 1-2% of the population and may be associated with important valvular disease and an increased risk of aortic root and/or ascending aortic aneurysm and dissection. BAV aortic aneurysm and dissection occur earlier in life than when these disorders are associated with a tricuspid aortic valve (TAV). Alterations in the aortic media and differences in aortic elastic properties and wall stress also accompany BAV aortopathy. With appropriate follow-up and timely surgery, population studies have documented a survival rate for patients with BAV no different from age-matched controls. Guidelines have previously recommended prophylactic aortic surgery at a smaller aortic aneurysm size for patients with BAV compared with aneurysms in patients with a TAV. Recent guidelines have presented differing indications regarding the appropriate timing of prophylactic surgery for BAV aneurysms, giving the recommendation for surgery when the aortic root and/or ascending aortic exceeds 5.5 cm (unless certain factors are present), the same size for which TAV-associated aortic aneurysm surgery is recommended. We review the pathophysiology of BAV aortopathy, the clinical history of BAV ascending aortic disease, areas of uncertainty and make a case for a patient-centered, individualised decision regarding the optimal timing of aortic aneurysm surgery in BAV disease.
authors.affiliation: Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Luigi
authors.initials: L
authors.lastname: Adamo
authors.affiliation: Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
authors.forename: Alan C
authors.initials: AC
authors.lastname: Braverman
mesh_terms: D000784:Aortic Dissection / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D001019:Aortic Rupture / Q000209:etiology / Q000517:prevention & control; D001021:Aortic Valve / Q000002:abnormalities* / Q000503:physiopathology; D001027:Aortography / Q000379:methods; D000082882:Bicuspid Aortic Valve Disease; D003661:Decision Support Techniques; D003952:Diagnostic Imaging / Q000379:methods*; D017548:Echocardiography, Transesophageal; D006349:Heart Valve Diseases / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology; D006439:Hemodynamics; D006801:Humans; D008279:Magnetic Resonance Imaging; D018579:Patient Selection; D055420:Perfusion Imaging / Q000379:methods; D011237:Predictive Value of Tests; D012039:Regional Blood Flow; D018570:Risk Assessment; D012307:Risk Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures