Page 27 - BH-3-3

Brain & Heart Modern imaging and management of bicuspid valves

of patients with BAV and AR demonstrated a 10-year in patients with BAV aortopathy using beta-blockers
event-free survival from major aortic complications (i.e., and/or inhibitors of the renin-angiotensin system (e.g.,
dissection, rupture, death, or the need for proximal aortic angiotensin receptor blockers). These recommendations are
surgery), compared to 93% in those with BAV and AS. extrapolated from evidence in individuals with connective
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Furthermore, a meta-analysis revealed that patients with tissue diseases, such as Marfan syndrome. 67,68,76,77 Beta-
BAV and AR are 10 times more likely to experience aortic adrenergic blockers are thought to reduce aortic wall shear
dissection compared to those with AS. For AR, the ACC/ stress, whereas angiotensin-receptor blockers have been
AHA guidelines recommend surgery for patients with shown to reduce the rate of aortic growth in patients with
severe regurgitation who either exhibit symptoms, show Marfan syndrome. Guidelines from AATS also include
signs of left ventricular dysfunction (e.g., left ventricular non-pharmacologic recommendations such as limiting
ejection fraction <50%), or have substantial left ventricular salt intake, smoking cessation, and weight management.
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dilation (e.g., left ventricular end-systolic dimension Intense isometric exertion and heavy weightlifting should
>50 mm). In addition, the American Association for be avoided in patients with aortopathy. Evidence suggests
3
Thoracic Surgery (AATS) advises considering aortic that the occurrence of an acute and sudden increase in
repair in patients with BAV and significant regurgitation systolic blood pressure to >300 mm Hg increases the risk
when the aortic diameter reaches 5 cm, particularly in of serious and life-threatening complications. A uniform
cases with an aortic root phenotype characterized by consensus; however, suggests that light weightlifting and
dilation. The David procedure, also known as aortic low-intensity aerobic exercise can benefit patients’ physical
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valve-sparing surgery, is another option, which involves and mental well-being. 74
the reimplantation of the aortic valve into a resected aortic
root. This procedure preserves the patient’s native valve 5.2. Surgical management
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and is typically used in patients with aortic root disease but Surgical approaches for BAV include valve replacement
without significant valve pathology. with either bioprosthetic or mechanical valves, the Ross

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4.3. Aortopathy procedure, the Ozaki procedure, and aortic valve repair.
AVR is the most common intervention for BAV stenosis
Guidelines emphasize the importance of individualized or incompetence in adulthood, and valvuloplasty is
decision-making for aortic repair in BAV patients. rarely performed. Surgical intervention for BAV disease
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The 2022 ACC/AHA guidelines provide a class I typically occurs at a younger age than degenerative TAVs
recommendation that, in patients with a BAV and a disease. 18,79 Table 2 outlines the surgical indications based
diameter of the aortic root, ascending aorta, or both of on current guidelines. Around 30% of adults requiring
≥5.5 cm, surgery is recommended to replace the aortic AVR also undergo aortic root surgery to mitigate the
root, ascending aorta, or both. There is a lower threshold risk of future root dilation. 79,80 AVR is a standard surgical
of 5 cm in the presence of additional risk factors, such procedure to treat severe aortic valve disease, such as
as rapid aortic growth (>5 mm/year), family history of AS or regurgitation, and can be performed with either a
aortic dissection, or coexisting severe valve pathology bioprosthetic or mechanical valve. Bioprosthetic valves,
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(e.g., regurgitation or stenosis). Similarly, the 2021 made from animal tissue, offer the advantage of a lower
European Society of Cardiology guidelines recommend risk of thrombosis than mechanical valves, which require
surgical intervention at a diameter of 5 cm for high-risk lifelong anticoagulation. However, bioprosthetic valves
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BAV patients, including those with systemic hypertension, have a shorter lifespan, particularly in younger patients.
coarctation of the aorta, or a family history of dissection. The surgical approach for AVR typically involves a median
For patients undergoing concurrent aortic valve surgery, sternotomy, providing excellent exposure to the heart and
the threshold for ascending aorta replacement is further aorta. In some cases, less invasive techniques are employed,
reduced to 4.5 cm when performed at experienced centers such as a hemisternotomy or a mini-thoracotomy, which
capable of achieving high success rates with valve-sparing offer smaller incisions and may result in quicker recovery
or combined procedures. 75
times and reduced post-operative pain. The choice of
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5. Treatment modalities surgical approach depends on the patient’s anatomy,
the surgeon’s experience, and the extent of the disease.
5.1. Medical management Still, each approach aims to provide a successful valve
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The medical management of patients with BAV aortopathy replacement with minimal complications. Bioprosthetic
emphasizes strict blood pressure control alongside valves offer the advantage of a lower risk of thrombosis and
comprehensive cardiovascular risk reduction strategies. eliminate the need for lifelong anticoagulation, making
The American AATS recommends treating hypertension them particularly suitable for older patients. In contrast,

Volume 3 Issue 3 (2025) 8 doi: 10.36922/BH025050008