Bicuspid Aortic Valve Repair: Causes of Valve Failure and Long-Term Outcomes

Background: Repair of bicuspid aortic valves (BAVs) for aortic regurgitation (AR) has favorable outcomes, but the impact of natural disease progression on durability of repair is uncertain. We evaluated causes of reoperation and compared outcomes of BAV repair to those of patients undergoing aortic valve replacement (AVR). Methods: Between January 1993 and December 2016, 113 patients had BAV repair at our institution for significant AR. Operative notes and pathology reports were studied to identify late causes of repair failure. For comparison with AVR, we utilized propensity score weighting with the score derived from preoperative and operative characteristics using gradient boosting machine model. Results: A total of 26 patients had late AVR after initial repair. Causes of late valve dysfunction included calcification or fibrosis of the cusps (68%), concomitant replacement addressing moderate degree of aortic valve disease to avoid future operation (20%), and cusp prolapse (12%). Pathological evaluation of these excised valves reported calcification and fibrosis in 88% of the valves. Ten-year survival of patients undergoing BAV repair was 91% compared with 90% for patients undergoing AVR with a mechanical valve and 79% for AVR with a bioprosthesis (P = .6). Incidence of reoperation after AVR with a bioprosthesis was similar to risk after repair whereas AVR with mechanical valve showed significant advantage. Conclusions: Disease progression with calcification or fibrosis is the most common cause of valve failure after initial repair of BAV. Clinical outcomes of BAV repair for severe AR appear superior to AVR with bioprosthesis.