Management of Symptomatic Bicuspid Aortic Regurgitation
For a patient with symptomatic bicuspid aortic valve regurgitation, surgical aortic valve replacement (either mechanical or bioprosthetic valve) is indicated regardless of left ventricular systolic function. 1, 2
Primary Recommendation: Surgical Aortic Valve Replacement
- Surgery is the definitive treatment for all symptomatic patients with severe aortic regurgitation, independent of LVEF or LV dimensions. 1, 2
- The presence of symptoms (dyspnea NYHA class II-IV or angina) constitutes a Class I, Level B indication for intervention. 1
- Operative mortality for isolated aortic valve surgery ranges from 1-3% in asymptomatic patients and 3-7% in symptomatic patients, making this a safe and effective intervention. 1
Why Not TAVR?
- TAVR should NOT be performed in patients with isolated severe AR who have indications for surgical AVR and are surgical candidates. 1
- TAVR is traditionally contraindicated in pure aortic regurgitation because the calcified landing zone is often lacking, removing anatomical landmarks for proper valve alignment and potentially leading to malposition. 1
- When TAVR has been attempted for AR, more than mild residual AR is associated with doubling of mortality at 1 year (22% vs 46%). 1
- TAVR may only be considered in experienced centers for selected patients who are ineligible for surgical AVR due to prohibitive surgical risk. 1
Valve Repair Considerations in Bicuspid Aortic Valve
- Aortic valve repair may be considered in selected patients at experienced centers when replacement of aortic sinuses and/or ascending aorta is performed. 1
- Bicuspid aortic valve repair has shown reintervention rates of approximately 20% at 10 years, with freedom from valve replacement of 49% at 10 years. 1, 3, 4
- Repair requires correction of all aspects simultaneously: resection of median raphe, subcommissural annuloplasty, reinforcement of leaflet free edge, and sinotubular junction plication. 5
- The most common causes for reoperation after repair are cusp prolapse (38%), progressive stenosis or regurgitation (17%), and AR from root aneurysm (15%). 4
Mechanical vs Bioprosthetic Valve Choice
- Both mechanical and bioprosthetic valves are acceptable options for surgical AVR in bicuspid AR. 1
- The choice depends on patient age, anticoagulation tolerance, lifestyle factors, and patient preference regarding reoperation risk versus lifelong anticoagulation.
- In younger patients with bicuspid valves (mean age 42 years in repair series), mechanical valves avoid early structural valve deterioration but require lifelong anticoagulation. 4
Why Follow-Up Alone is Inadequate
- Once symptoms develop in severe AR, mortality increases dramatically from 6% per year to 25% per year. 1
- Within 10 years of diagnosis of severe AR, 75% of patients die or require aortic valve replacement. 1
- Symptoms herald left ventricular decompensation, and delaying surgery after symptom onset leads to worse postoperative outcomes including persistent LV dysfunction and reduced long-term survival. 1
Concomitant Aortic Root Management
- If surgery is indicated for severe AR and the aortic root diameter is ≥45 mm in bicuspid valve patients, replacement of the aortic sinuses and/or ascending aorta should be performed. 1
- For bicuspid valve patients with risk factors (family history of dissection, rapid growth >2mm/year), surgery on the aorta should be considered at ≥50 mm. 1
Answer to Multiple Choice
The correct answer is B - mechanical valve (or bioprosthetic valve as part of surgical AVR). TAVR (option A) is contraindicated in surgical candidates with isolated AR, and follow-up alone (option C) is inappropriate once symptoms develop given the high mortality risk. 1, 2