Key result
2-sinus BAV linked to ~2.6-fold higher risk of redo-AVR, endocarditis, or death vs fused morphology.
Why the study?
The two most common bicuspid aortic valve phenotypes, 2-sinus BAV and fused BAV, differ in geometric characteristics and underlying pathophysiological mechanisms of valve dysfunction, which could influence short-term complications and long-term prognosis following aortic valve replacement.
Does 2-sinus BAV morphology compared to fused BAV morphology increase short-term and long-term complications following aortic valve replacement in adult patients with bicuspid aortic valve disease?
Cohort (n=276)
Does 2-sinus BAV morphology compared to fused BAV morphology increase short-term and long-term complications following aortic valve replacement in adult patients with bicuspid aortic valve disease?
In patients with bicuspid aortic valve undergoing aortic valve surgery, the 2-sinus BAV phenotype is associated with more than double the risk of both 30-day surgical complications and long-term adverse outcomes compared to the fused BAV phenotype.
Answers are grounded in this paper and cite their sources.
2-sinus BAV morphology was associated with higher post-AVR risks; leaves open whether phenotype-specific strategies improve outcomes.
Background Bicuspid aortic valves (BAV) exhibit diverse morphological patterns. The two most common phenotypes are the 2-sinus BAV and the fused BAV. These phenotypes differ in their geometric characteristics, and their valve dysfunction may arise from distinct underlying pathophysiological mechanisms, both of which could influence outcomes following aortic valve replacement (AVR). Purpose To evaluate differences in short-term complications and long-term prognosis following aortic valve surgery among patients with bicuspid aortic valve according to valve morphology. Methods From a prospective cohort study of adult BAV outpatients followed in the period 2018-2024, we identified 276 cases who underwent AVR during follow-up and who had either a 2-sinus (n=44/15.9%) or fused (n=232/84.1%) BAV morphology. Short-term complications were assessed at 30-days following surgery and we compared a composite of re-interventions (redo-AVR, surgery to stop major bleeding, pericardiocentesis, or re-hospitalization with pleuracentesis) and all-cause mortality using logistic regression. Furthermore, the following complications were assessed at end of follow-up: re-do AVR, endocarditis, and all-cause mortality. We estimated the overall event-free survival using the Kaplan Meier-estimator and compared the hazard of having any of these events using Cox regression. We considered sex and age at time of surgery as possible confounders. Results Median age of the cohort was 62.5 [54.9, 69.3] years with no difference between morphology subgroups (p=0.6). Surgical details are compared between the subgroups in Table 1. Groups were very similar, with the exception that the frequency of pericardial patch repair during surgery was slightly higher in the 2-sinus BAV subgroup (9.1% vs. 1.3%, p=0.01). In total, 75 (27.2%) patients experienced one of the short-term complications and the risk was increased in patients with 2-sinus BAV (unadjusted odds ratio= 2.13, 95% CI (1.09; 4.16), p=0.03) and (adjusted odds ratio=2.26, 95%CI (1.14; 4.46), p=0.02). During a median follow-up of 4.4 years (interquartile range: 2.1- 5.6), there were 10 cases (3.6%) of endocarditis, 8 re-do surgeries (2.9%) and 10 patients died (3.6%). In total, 14 patients developed a primary composite endpoint and the estimated event-free survival 5 years after surgery was 89.4%, 95%CI (85.3%; 93.6%). The hazard of the composite endpoint was higher in patients with 2-sinus BAV with a crude hazard ratio of 2.34, (95% CI (0.97; 5.64), p = 0.06) and an adjusted hazard ratio of 2.62 (95%CI (1.08; 6.35), p=0.03, figure 1 Cumu). Conclusion In this observational study of bicuspid aortic valve patients undergoing aortic valve surgery, a 2-sinus BAV morphology was associated with increased risks of short-term and longer-term complications.
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Wulffeld et al. (2026) conducted a cohort in Bicuspid aortic valve disease undergoing aortic valve replacement (n=276). 2-sinus bicuspid aortic valve morphology vs. Fused bicuspid aortic valve morphology was evaluated on Composite of re-do aortic valve replacement, endocarditis, and all-cause mortality (HR 2.62, 95% CI 1.08-6.35, p=0.03). 2-sinus bicuspid aortic valve morphology vs fused morphology increased the risk of redo-AVR, endocarditis, or mortality after surgery (aHR 2.62; 95% CI 1.08-6.35; P=0.03).
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