Bicuspid aortic valve disease and associated ascending aortic aneurysm: Composite root replacement or separate valve and graft replacement?

Purpose: Bicuspid aortic valve disease can be associated with aneurysmal dilatation of the ascending aorta. The optimal management of this condition is not well defined. The purpose of this study was to compare outcomes for patients with bicuspid aortic valve disease undergoing replacement of the aortic valve and ascending aorta by either a composite valve-graft (CVG) or separate valve-graft (SVG) conduit. Methods: Between January 1985 and January 1998, 46 patients with bicuspid aortic valve disease and ascending aortic aneurysms underwent either CVG (n=19) or SVG (n=27). Preoperative patient characteristics and postoperative outcome variables were analyzed using stepwise logistic regression analysis. Results: Patients undergoing CVG were typically younger than those undergoing SVG (42.4 vs. 60.0 yrs, p<0.05). There were no other statistical differences in preoperative patient characteristics including sex, previous myocardial infarction, hypertension, smoking, renal failure, stroke, diabetes, obesity, and previous cardiac surgical procedures. The 30-day perioperative mortality rate was 4.4% for all patients. There were no statistically-significant differences in mortality between patients undergoing CVG (0%) versus SVG (7.4%), p=0.98. In addition, no statistically-significant differences in perioperative outcomes were found, as manifested by the need for intraoperative or postoperative blood transfusions, reexploration for bleeding, cardiac tamponade, atrial or ventricular arrhythmias, complete heart block, sepsis, pneumonia, stroke, renal failure, prolonged mechanical ventilation, cardiopulmonary bypass time, aortic cross-clamp time, circulatory arrest, and length of stay (p=NS). Long-term follow-up data was available for 36 patients, with a mean follow-up of 2.8 years (range: 0.02-9.81 years). Kaplan-Meier actuarial survival following CVG was not statistically different from SVG (p=0.82). Only one patient who had a previous SVG necessitated reoperation. Conclusions: Both perioperative morbidity and mortality, and long-term morbidity and mortality are not increased by the use of a CVG compared to a SVG for patients with bicuspid aortic valve disease and ascending aortic aneurysms. Clinical Implications: These data support the use of a CVG conduit in the setting of bicuspid aortic valve disease and aneurysmal dilatation of the ascending aorta. This is especially indicated in younger patients in whom this approach provides protection against future dilatation of the sinuses at no significantly increased short-term or long-term risk.