Page 28 - BH-3-3

Brain & Heart Modern imaging and management of bicuspid valves

Table 2. Surgical indications by contemporary guidelines
Condition Surgical indications Guidelines
Bicuspid aortic valve • Recommended for symptomatic severe AS. a,c 2020 ACC/AHA Guidelines
stenosis • Recommended for severe AS in patients undergoing other cardiac surgery. a,d for VHD
• AVR is recommended for asymptomatic patients with severe AS and a LVEF below 50%. a.c
• In individuals with severe AS who are asymptomatic but have a valve area <0.6 cm², surgical
intervention is strongly advised. a,d
• Asymptomatic patients with severe AS undergoing other cardiac surgeries should also receive
AVR during the same operative session. a,d
• AVR is indicated in patients presenting with symptoms and severe aortic stenosis. a,d 2021 ESC/EACTS
• For individuals with severe low‑flow, low‑gradient AS and an LVEF below 50%, AVR is Guidelines for VHD
recommended when contractile (flow) reserve is demonstrated during testing. a,d
• In asymptomatic patients with severe AS and an LVEF under 50% with no other identifiable
cause for dysfunction, surgical intervention is warranted. a,d
• Asymptomatic individuals with severe AS who develop symptoms during exercise testing should
also be considered for AVR. a,e
Bicuspid aortic valve • Recommended in patients with symptomatic severe AR. a,d 2020 ACC/AHA Guidelines
regurgitation • In asymptomatic patients with chronic severe AR and a LVEF of 55% or lower, aortic valve for VHD
surgery is recommended, provided that no alternative explanation for systolic dysfunction
exists. a,d
• For asymptomatic individuals with severe AR and preserved LVEF (>55%), surgical intervention
is reasonable when there is marked left ventricular dilation, defined as LVESD >50 mm or
LVESD >25 mm/m². b,d
• Patients with severe AR undergoing cardiac surgery for other indications should also receive
aortic valve surgery during the procedure. a,e
• Recommended in symptomatic patients with severe AR. a,d 2021 ESC/EACTS
• Recommended in asymptomatic patients with LVESD >50 mm or LVESD >25 mm/m BSA or Guidelines for VHD
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resting LVEF ≤50%. a,d
• Severe AR undergoing CABG or surgery of the ascending aorta or of another valve. a,e
Aortopathy • For individuals – whether symptomatic or not – with an aortic sinus or ascending aortic diameter 2020 ACC/AHA Guidelines
associated with exceeding 5.5 cm, surgical replacement of the affected aortic segment is strongly recommended. a,d for VHD
bicuspid valves • In asymptomatic patients with an aortic sinus or ascending aortic diameter between 5.0 and
5.5 cm, surgery may be considered appropriate if additional risk factors for dissection are present
– such as a family history of aortic dissection, rapid aortic expansion (>5 mm/year), or coexisting
aortic coarctation – especially when performed at a Comprehensive Valve Center. b,d
• Surgical intervention is indicated for ascending aortic aneurysms involving the root or tubular 2021 ESC/EACTS
segment when the aortic diameter reaches ≥55 mm. a,d Guidelines for VHD
• For patients with BAV‑associated aortopathy displaying a root phenotype, surgery is
recommended at a diameter threshold of ≥50 mm. a,d
• In low‑risk surgical candidates with ascending phenotype aortic dilation, operative management
should be considered when the diameter exceeds 52 mm. b,e
• In low‑risk surgical candidates with ascending phenotype BAV aortopathy, a lower surgical
threshold of ≥50 mm may be appropriate when additional risk factors are present, such as: age
under 50 years, height below 1.69 meters, ascending aortic length >11 cm, annual aortic growth
>3 mm, positive family history of acute aortic syndromes, associated aortic coarctation, poorly
controlled hypertension, patient preference, or need for concomitant cardiac surgery unrelated to
the aortic valve.
• Valve‑sparing root replacement may be a viable option for patients with a structurally normal
bicuspid valve and isolated root enlargement, provided experienced surgeons in aortic valve
repair perform the procedure. d,f
Notes: Class 1 or COR A indicates a strong recommendation. The treatment or procedure is beneficial, useful, and effective; Class 2a indicates
b
a
a moderate recommendation. The treatment or procedure is reasonable and can be considered; LOE A is high-quality evidence from multiple
c
randomized controlled trials (RCTs) or a meta-analysis of high-quality RCTs; LOE B-NR is non-randomized, evidenced from well-designed
d
non-randomized studies; LOE C indicates expert opinions; Class 2b suggests a moderate recommendation but with a lower level of evidence. The
e
f
treatment or procedure may be considered, depending on the clinical situation.
Abbreviations: ACC: American College of Cardiology; AHA: American Heart Association; AR: Aortic Regurgitation; AS: Aortic Stenosis, AVR: Aortic
valve replacement; BAV: Bicuspid aortic valve; BSA: Body surface area; CABG: Coronary artery bypass grafting; COR: Class of recommendation;
EACTS: European Association for Cardio-Thoracic Surgery; ESC: European Society of Cardiology; LOE: Level of evidence; LVEF: Left ventricular
ejection fraction; LVESD: Left ventricular end-systolic dimension; VHD: Valvular heart disease.
Volume 3 Issue 3 (2025) 9 doi: 10.36922/BH025050008