The surgical implications of bicuspid aortopathy.

It should not be a surprise that there is great interest today in bicuspid aortic valve (BAV) and, in particular, its associated aortopathy; perhaps it is more surprising that so little seems to be known about this most common type of congenital cardiac anomaly. Affecting between 0.5-2% of the general population, and men three times more often than women (1,2), BAV is frequently the underlying etiology of aortic valve dysfunction in the form of calcific aortic stenosis or aortic regurgitation and is often associated with other congenital and acquired cardiac anomalies. Beyond the valve itself, there is growing appreciation of the potential for mortality imposed by the associated proximal ascending aortic aneurysm which predisposes the aorta to dissection. Necropsy studies have long suggested an up to nine-fold increased risk of aortic dissection in patients with BAV compared to patients with tricuspid valves based simply on numerical over-representation of the former (3). Given technical progress and improving results of aortic surgical interventions (4), recent years have witnessed adoption of a distinctly more aggressive posture among both surgeons and cardiologists towards replacement of even modestly dilated aorta in the presence of BAV. The question remains whether the momentum of this shift in opinion has led us to overshoot the mark.