When to Operate on the Bicuspid Valve Patient With a Modestly Dilated Ascending Aorta Christian D. Etz, MD, PhD, Stefano Zoli, MD, Robert Brenner, MS,

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When to Operate on the Bicuspid Valve Patient With a Modestly Dilated Ascending Aorta Christian D. Etz, MD, PhD, Stefano Zoli, MD, Robert Brenner, MS, Fabian Roder, MS, Moritz Bischoff, MD, Carol A. Bodian, DrPH, Gabriele DiLuozzo, MD, Randall B. Griepp, MD The Annals of Thoracic Surgery Volume 90, Issue 6, Pages 1884-1892 (December 2010) DOI: 10.1016/j.athoracsur.2010.06.115 Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Between 1988 and 2008, a total of 158 consecutive patients with functionally normal bicuspid aortic valves (BAV) and ascending aortic dilatation were surveyed. Forty-two patients with a mean ascending tubular diameter of 5.6 ± 0.5 cm underwent immediate surgery. One hundred sixteen patients entered the surveillance program with initial mean tubular ascending diameters of 4.6 ± 0.5 cm; 45 had two or more digitized computed tomographic scans at least 150 days apart. Another forty-five patients with a mean tubular ascending diameter of 4.9 ± 0.6 cm underwent surgery an average 3.4 ± 2.9 years after their first scan. Twenty-six patients had one scan only. The Annals of Thoracic Surgery 2010 90, 1884-1892DOI: (10.1016/j.athoracsur.2010.06.115) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Typical drawing of the 3D reconstruction of the aorta based on individually digitized CT scan as used to assess the entire aorta periodically during surveillance. Serial CT scans were digitized, providing diameter and area data of the ascending aorta, the transverse arch, and the descending and thoracoabdominal aorta. The tubular ascending aorta was individually identified in each 3D reconstruction and an estimate of the diameter of the tubular ascending aorta was calculated using the mean of the minor diameters of all ellipsoid CT slices contributing to the tubular ascending aorta. The Annals of Thoracic Surgery 2010 90, 1884-1892DOI: (10.1016/j.athoracsur.2010.06.115) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Tubular AA diameter at index computed tomographic scan versus age of each individual patient entering the program; patients under surveillance (n = 116) versus immediate surgery (n = 42). (Data for normal ascending aorta (*) and normal ascending aorta: upper limit (*) are from Hannuksela M, Lundqvist S, Carlberg B. Thoracic aorta—dilated or not? Scand Cardiovasc J 2006;40:175–8.) The Annals of Thoracic Surgery 2010 90, 1884-1892DOI: (10.1016/j.athoracsur.2010.06.115) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Long-term outcome of patients with bicuspid aortic valves (BAV) and ascending aortic dilatation that underwent immediate surgery (N = 42) versus patients who entered the surveillance program (N = 116) with or without elective surgery. The Annals of Thoracic Surgery 2010 90, 1884-1892DOI: (10.1016/j.athoracsur.2010.06.115) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Average growth of the ascending aorta in patients (n = 116) with normally functioning bicuspid aortic valve versus normal, age-related expansion. (Data for dotted line in this figure are derived from Hannuksela M, Lundqvist S, Carlberg B. Thoracic aorta—dilated or not? Scand Cardiovasc J 2006;40:175–8.) The Annals of Thoracic Surgery 2010 90, 1884-1892DOI: (10.1016/j.athoracsur.2010.06.115) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Long-term outcome of patients (N = 158) with BAV and ascending aortic dilatation (Kaplan-Meier survival curve starting with the first encounter) versus age-matched and sex-matched NY State population. The Annals of Thoracic Surgery 2010 90, 1884-1892DOI: (10.1016/j.athoracsur.2010.06.115) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions