Long-term outcomes of aortic root procedures for heterogenous ascending aneurysm disease in bicuspid aortic valve syndrome

Published:November 23, 2022DOI:
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      Surgery for ascending aneurysms in bicuspid aortic valve (BAV) 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.


      From 1997 to 2017, 635 BAV patients undergoing root complex focused procedures electively were stratified by valvulopathy (aortic stenosis (AS) versus insufficiency (AI)) and sub-stratified into ascending or root aneurysm phenotype. Inverse probability weights were calculated to adjust for baseline differences.


      Kaplan-Meier curves for all-cause mortality demonstrated no difference between Bentall versus AVRSCAAR for AS and AI presentations (log-rank p>0.05). In AS patients, multivariable Cox regression showed significantly decreased risk of stroke for biologic AVRSCAAR (HR 0.04, p=0.013). Aortic reoperation rates were similar for biologic versus mechanical valves (p=0.353).
      In AI patients, similar long-term mortality (HR 0.95, p=0.93), but lower stroke risk in biologic AVRSCAAR group by Cox regression, and lower aortic reoperation rate was noted (coefficient <0.01, p<0.001). Comparing Bentall to VSRR, mortality (HR 0.12, p=0.022) was significantly improved in VSRR subjects, but recurrence of ≥ moderate AI was higher in VSRR by multistate model (coefficient 2.63, p<0.001).


      A tailored approach to heterogeneous ascending aneurysm pathologies in BAV syndrome utilizing Bentall, AVRSCAAR, and VSRR procedures renders excellent long-term clinical and functional outcomes, with biologic conduits showing equivalent to improved clinical outcomes.

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      Key Words

      Abbreviations and Acronyms:

      BAV (Bicuspid Aortic Valve), AS (Aortic Stenosis), AI (Aortic Insufficiency), AVR (Aortic Valve Replacement), AVRSCAAR (Aortic Valve Replacement and SupraCoronary Ascending Aorta Replacement), VSRR (Valve Sparing Root Reimplantation)
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