Fate of nonreplaced sinuses of Valsalva in bicuspid aortic valve disease

Objective: There is growing consensus that the ascending aorta should be replaced at the time of aortic valve replacement for bicuspid aortic valve even if it is only moderately dilated; the natural history of nonreplaced sinuses of Valsalva is less clear. Methods: We identified patients without defined connective tissue disorder undergoing primary aortic valve replacement for bicuspid aortic valve and separate repair of the ascending aorta without root replacement at the Mayo Clinic between January 1, 1988, and December 31, 2007. Results: Among 218 patients, 65 underwent ascending aortoplasty and 153 underwent separate graft replacement of the ascending aorta. Of the latter group, 15 also had graft replacement of the noncoronary sinus. The mean age at operation was 62 ± 13 years. Valvular dysfunction was predominantly stenosis in 151 patients (70%), regurgitation in 54 patients (25%), and mixed in 12 patients (5%). At a follow-up of up to 17 years (median, 3.3 years; range, 0-17 years), 10 patients (5%) had undergone late reoperation, of whom 1 had replacement of the ascending aorta and 1 had replacement of the root for significant dilatation of the sinuses. Both patients had originally undergone aortoplasty. No other patient required root surgery. One-, 5-, and 10-year freedom from reoperation for any cause were 97.6%, 94.9%, and 85.5%, respectively. Conclusions: Although progressive ascending aortic dilatation after aortic valve replacement for bicuspid aortic valve is well documented, progressive dilatation of nonreplaced sinuses is not evident. Separate valve and graft repair remains a reasonable surgical option in the setting of aortic valve replacement for bicuspid aortic valve with ascending aortic dilatation provided the sinuses of Valsalva are not significantly enlarged.