Bicuspid Aortic Valve with Aortopathy — EECC MCQ

Correct answer: C — Prophylactic aortic root replacement with or without aortic valve intervention

In a 40-year-old with bicuspid aortic valve, an ascending aorta measuring 52 mm is pathological aneurysmal dilatation and is beyond the usual threshold at which prophylactic surgery on the aortic root/ascending aorta is recommended or should be strongly considered in UK-compatible European practice, particularly in a young, otherwise operable patient. The indication is the bicuspid-valve-associated aortopathy and prevention of dissection/rupture, not the severity of aortic regurgitation. His aortic regurgitation is only moderate, and he is asymptomatic with preserved LV systolic function (LVEF 60%) and no LVESD trigger for isolated aortic valve surgery; however, when the aorta is replaced, the bicuspid valve may be repaired or replaced depending on valve anatomy and the degree/mechanism of regurgitation. TAVI is not appropriate for moderate AR and does not treat the aneurysmal ascending aorta; surveillance or losartan alone would undertreat a 52 mm bicuspid aortopathy; and the aortic dilatation is not ‘normal’ for a bicuspid valve. Therefore the most appropriate management is prophylactic aortic root/ascending aortic replacement with or without aortic valve intervention.

Reference: 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases, section on aortic disease associated with bicuspid aortic valves: https://academic.oup.com/eurheartj/article/45/36/3538/7738955