Aortic valve phenotype and distal aortic outcome after ascending aortic surgery

Recent guidelines advocate postoperative aortic surveillance without clear distinction between aortic valve phenotypes. We sought to determine the long-term occurrence and location of distal aortic complications and aortic growth rates postoperatively in patients with bicuspid and tricuspid aortic valves, respectively.

Patients underwent elective ascending aorta replacement, with or without concomitant aortic valve surgery, and computed tomography of the aorta preoperatively. Repeat imaging was performed 10 years after surgery and medical records were reviewed to identify aortic events.

Overall, 127 patients (bicuspid n = 85 [66.9%], tricuspid n = 42 [33.1%]; male n = 88 [69.3%]) were included at baseline. Ten patients (23.8%) in the tricuspid group developed an acute aortic event, indication for surgery at a distal segment, or underwent aortic intervention, compared with two (2.4%) in the bicuspid group (p < 0.001). 96 patients (75.6%, bicuspid n = 67, tricuspid n = 29) returned for repeat aortic imaging, with a median follow-up of 10.8 years. The frequency of arch complications was significantly higher in the tricuspid group (n = 4 vs. n = 0, p = 0.007). Multivariable logistic regression identified tricuspid aortic valve (OR 8.52, p = 0.012) and baseline distal aortic diameter (OR 1.27 per mm increment, p < 0.001) as risk factors for a distal aortic complication.

Patients with a tricuspid aortic valve are at high risk of a distal aortic complication, whereas patients with a bicuspid aortic valve are at low risk. Long-term surveillance should be individualized accordingly.