Aortic valve replacement in patients with significant aortic regurgitation: Comparing bicuspid and tricuspid aortic valve outcomes

The role of bicuspid aortic valve (BAV) morphology in left ventricular (LV) remodelling and outcomes in aortic regurgitation (AR) patients undergoing surgical aortic valve replacement (SAVR) remains unclear. This study compares LV function and postoperative outcomes in patients with moderate-to-severe AR, stratified by BAV versus tricuspid aortic valve (TAV) morphology. We retrospectively analyzed 323 patients with isolated moderate-to-severe AR undergoing SAVR (BAV: n = 70; TAV: n = 253). Baseline clinical, echocardiographic, surgical, and follow-up data were evaluated. Adverse events were defined as a composite of all-cause mortality and heart failure rehospitalization. Patients with BAV were a decade younger, were less symptomatic, but had smaller indexed aortic valve areas (AVAi) and greater regurgitant volumes. Patients with BAV had greater rise in indexed stroke volumes (SVi) with rising indexed LV end-diastolic volumes (LVEDVi) (p interaction = 0.008), and milder LV ejection fraction decline with increasing LV end-systolic diameter (LVESD) (p interaction = 0.004). Patients with BAV experienced less adverse events (16 % vs 30 %, p = 0.014). AVAi and indexed LV mass (LVMi) independently predicted adverse events after multivariable adjustment and age-matching, while valve morphology did not. In patients requiring SAVR for isolated AR, patients with BAV had more severe valve dysfunction at a younger age but more preserved systolic function with LV dilation. AVAi and LVMi independently predict postoperative outcomes, supporting their use for risk stratification and timely intervention, especially in younger BAV patients. • Patients with BAV-AR were younger and had more advanced valvular disease before surgery. • Patients with BAV-AR had more preserved LV function despite more severe AR. • Indexed aortic valve area and LV hypertrophy may guide optimal AVR timing in AR.