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BAV Aortopathy Impact on Valve Decision — EECC MCQ

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ModerateValvular Heart DiseaseBAV Aortopathy Impact on Valve DecisionEECC

A 72-year-old man with severe symptomatic aortic stenosis has a CT showing a bicuspid aortic valve with heavy raphe calcification and an ascending aortic diameter of 48 mm. He is being assessed for TAVI vs SAVR. Does the associated aortopathy affect the valve intervention decision?

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Correct answer: E — Yes — if the ascending aorta is ≥45 mm in a BAV patient, combined AVR + ascending aortic replacement is recommended, which mandates SAVR (TAVI cannot address the aorta); the aortopathy in BAV is independent of valve haemodynamics and persists even after AVR

Bicuspid aortic valve is associated with aortopathy (ascending aortic dilatation/aneurysm) in 20-80% of patients, independent of haemodynamic severity. The aortopathy is caused by intrinsic medial degeneration (similar to but distinct from Marfan) and persists even after AVR (it is NOT caused by post-stenotic dilatation alone). The 2025 ESC VHD and 2024 ESC Aortic Disease Guidelines recommend: (1) concomitant ascending aortic replacement when aorta ≥45 mm at the time of AVR for BAV; (2) this mandates SURGICAL approach (TAVI cannot address the aorta); (3) aortic surveillance continues lifelong after isolated AVR if the aorta was not replaced; (4) standalone prophylactic aortic replacement may be considered at ≥50 mm (lower in the presence of risk factors: family history, growth >3 mm/year, coarctation). This is a critical consideration in the TAVI-vs-SAVR Heart Team discussion for BAV patients.

Reference: ESC/EACTS (2025): VHD; ESC (2024): Aortic Disease