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Surgical threshold for bicuspid aortic valve aneurysm: a case for individual decision-making
  1. Luigi Adamo,
  2. Alan C Braverman
  1. Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
  1. Correspondence to Alan C. Braverman, Cardiovascular Division, Department of Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Box 8086, St. Louis, Missouri 63110, USA; abraverm{at}


The bicuspid aortic valve (BAV) affects 1–2% of the population and may be associated with important valvular disease and an increased risk of aortic root and/or ascending aortic aneurysm and dissection. BAV aortic aneurysm and dissection occur earlier in life than when these disorders are associated with a tricuspid aortic valve (TAV). Alterations in the aortic media and differences in aortic elastic properties and wall stress also accompany BAV aortopathy. With appropriate follow-up and timely surgery, population studies have documented a survival rate for patients with BAV no different from age-matched controls. Guidelines have previously recommended prophylactic aortic surgery at a smaller aortic aneurysm size for patients with BAV compared with aneurysms in patients with a TAV. Recent guidelines have presented differing indications regarding the appropriate timing of prophylactic surgery for BAV aneurysms, giving the recommendation for surgery when the aortic root and/or ascending aortic exceeds 5.5 cm (unless certain factors are present), the same size for which TAV-associated aortic aneurysm surgery is recommended. We review the pathophysiology of BAV aortopathy, the clinical history of BAV ascending aortic disease, areas of uncertainty and make a case for a patient-centered, individualised decision regarding the optimal timing of aortic aneurysm surgery in BAV disease.

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