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J Thorac Cardiovasc Surg 2008;135:901-907
© 2008 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch

^a Department of Cardiothoracic Surgery, Stanford University Medical School, Stanford, Calif
^b Department of Radiology, Stanford University Medical School, Stanford, Calif
^c Cardiovascular Medicine Division, Stanford University Medical School, Stanford, Calif

Received for publication August 2, 2007; revisions received December 22, 2007; accepted for publication January 23, 2008.

^_* Address for reprints: D. Craig Miller, MD, Department of Cardiothoracic Surgery, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, California 94305-5247. (Email: dcm{at}stanford.edu).

Objectives: Bicuspid aortic valves are associated with a poorly characterized connective tissue disorder that predisposes to aortic catastrophes. Because no criterion exists dictating the appropriate extent of aortic resection in aneurysmal disease of the bicuspid aortic valve, we studied the patterns of aortic dilation in this population.

Methods: Sixty-four patients with bicuspid aortic valves who underwent computed tomographic or magnetic resonance angiography and echocardiography were retrospectively identified between January 2002 and March 2006. Orthonormal 2–dimensional or 3-dimensional aortic diameters were measured at 10 levels. Agglomerative hierarchic clustering with centered correlation distance measurements and complete linkage analysis was used to detect distinct patterns of aortic dilatation.

Results: Mean aortic diameter was 28.1 ± 0.7 mm at the annulus and 21.7 ± 0.4 mm at the diaphragmatic hiatus. The aorta was largest in the tubular ascending aorta (45.9 ± 1.0 mm). Compared with the descending aorta, the transverse aortic arch was also dilated (P < .01). Cluster analysis showed 4 patterns of aortic dilatation: cluster I, aortic root alone (n = 8, 13%); cluster II, tubular ascending aorta alone (n = 9, 14%); cluster III, tubular portion and transverse arch (n = 18, 28%); and, cluster IV, aortic root and tubular portion with tapering across the transverse arch (n = 29, 45%).

Conclusion: Distinct patterns of aortic dilatation in patients with bicuspid aortic valves call for an individualized degree of aortic replacement to minimize late aortic complications and reoperation. Patients in clusters III and IV should have transverse arch replacement (plus concomitant root replacement in cluster IV). Patients in cluster I should undergo complete aortic root replacement, whereas in patients in cluster II supracommissural ascending aortic grafting is adequate.

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