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February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e110

CLINICAL STATEMENTS AND GUIDELINES Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

with serial imaging, 47% required valve surgery but only 3.8% required aortic grafting without valve replacement, and <0.1% had aortic dissection.5 In a systematic review of 13 studies with >11 000 patients with a BAV, aortic dilation was present in 20% to 40%, but only 0.4% suffered aortic dissection.1 Aortic imaging at least annually is prudent in patients with BAV and significant aortic dilation (>4.5 cm) to determine the appropriate timing of surgical intervention. Patients with risk factors that increase the risk of aortic dissection, such as a rapid rate of change in aortic diameter or a family history of aortic dissection, may also require more frequent monitoring. In patients with milder dilation that shows no change on sequential studies and with a negative family history, a longer interval between imaging studies is appropriate.1–4,8,9 2.	 In a retrospective review of 1286 patients with a BAV who underwent isolated AVR with a median of 12 years of follow-up, subsequent aortic dissection occurred in 1%, ascending aortic replacement surgery was needed in 0.9%, and progressive aortic enlargement was noted in 9.9%.6 In a smaller cohort of 153 patients with a BAV with prior AVR, 3% required proximal aortic surgery after 15 years of follow-up. No cases of aortic dissection were noted.7,10 These studies demonstrate that the aorta may continue to dilate in patients with a BAV who undergo valve replacement surgery.11

5.1.2 Interventions for Patients With BAV

5.1.2.1 Intervention: Replacement of the Aorta

Recommendations for Intervention: Replacement of the Aorta in Patients With a BAV Referenced studies that support the recommendations are summarized in Online Data Supplement 18. COR LOE Recommendations

1 B-NR 1.  In asymptomatic or symptomatic patients with a BAV and a diameter of the aortic sinuses or ascending aorta >5.5 cm, operative intervention to replace the aortic sinuses and/ or the ascending aorta is recommended.1–3

2a B-NR 2.  In asymptomatic patients with a BAV, a diameter of the aortic sinuses or ascending aorta of 5.0 to 5.5 cm, and an additional risk factor for dissection (eg, family history of aortic dissection, aortic growth rate >0.5 cm per year, aortic coarctation), operative intervention to replace the aortic sinuses and/or the ascending aorta is reasonable if the surgery is performed at a Comprehensive Valve Center.3,4

Figure 5. Intervals for imaging the aorta in patients with a BAV. Colors correspond to Table 2. BAV indicates bicuspid aortic valve; CTA, computed tomographic angiography; CMR, cardiac magnetic resonance; TTE, transthoracic echocardiography.

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