Effect of aortic aneurysm replacement on outcomes after bicuspid aortic valve surgery: Validation of contemporary guidelines

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.