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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e111 CLINICAL STATEMENTS AND GUIDELINES 2a B-NR 3. In patients with a BAV with indications for SAVR and a diameter of the aortic sinuses or ascending aorta ≥4.5 cm, replacement of the aortic sinuses and/or ascending aorta is reasonable if the surgery is performed at a Comprehensive Valve Center.4–7 2b C-LD 4. In patients with a BAV who meet criteria for replacement of the aortic sinuses, valve-sparing surgery may be considered if the surgery is performed at a Comprehensive Valve Center.8,9 2b B-NR 5. In asymptomatic patients with a BAV who are at low surgical risk, have a diameter of the aortic sinuses or ascending aorta of 5.0 to 5.5 cm, and have no additional risk factors for dissection, operative intervention to replace the aortic sinuses and/or the ascending aorta may be considered if the surgery is performed at a Comprehensive Valve Center.4–7,10–14 Synopsis The timing and type of surgery for replacement of the aorta are dependent on the anatomy of the aorta (as demonstrated on imaging), patient characteristics, and institutional expertise (Figure 6). Recommendation-Specific Supportive Text 1. Retrospective studies of patients with a BAV have shown that the incidence of aortic dissection is very low and is estimated to be approximately 0.4% with routine surveillance of the aorta.1 However, data are limited with regard to the degree of aortic dilation at which the risk of dissection is high enough to warrant operative intervention in patients who do not fulfill criteria for AVR on the basis of severe AS or AR. Thus, an individualized approach to the timing of surgical intervention for a dilated aorta is suggested. Surgery is recommended in patients with a BAV with or without symptoms and with a diameter of the aortic sinuses or the ascending aorta of ≥5.5 cm.2 2. Specific risk factors, including family history of aortic dissection, aortic growth rate >0.5 cm per year, and aortic coarctation, are associated with a greater risk of aortic dissection. In patients with these risk factors, operative intervention to replace the aortic sinuses and/or the ascending aorta is reasonable when the aortic dimension is 5.0 to 5.5 cm, if the surgery is performed at a Comprehensive Valve Center.4,10–12,15 3. In patients with a BAV, data are limited with regard to the degree of aortic dilation at which the risk of dissection is high enough to warrant replacement of the ascending aorta at the time of AVR. The risk of progressive aortic dilation and dissection after AVR in patients with BAV has been the subject of several studies, but definitive data are lacking. In patients undergoing AVR because of severe AS or AR, replacement of the ascending aorta is reasonable when the aortic diameter is >4.5 cm.4–7,10–14 4. There are a limited number of patients with BAV who meet criteria for operative intervention on the aortic sinuses and/or ascending aorta but have a well-functioning aortic valve. Because of the growing experience with valve-sparing surgery on highly selected patients,8,9 surgical replacement of the aorta with aortic valve repair or reimplantation may be considered. However, given the complexity of this procedure, surgery should be performed at a Comprehensive Valve Center. 5. Data are limited with regard to the degree of aortic dilation at which the risk of dissection is high enough to warrant operative intervention in patients who do not fulfill criteria for AVR on the basis of severe AS or AR. In asymptomatic patients with a BAV and a diameter of the aortic sinuses and/or ascending aorta of 5.0 to 5.5 cm who are at low surgical risk and have no additional risk factors for aortic dissection, surgery to replace the aortic sinuses and/or ascending aorta may be considered as long as surgery is performed at a Comprehensive Valve Center. Additionally, shared decision-making between the patient and the healthcare team is needed to clearly outline the risks of surgery and weigh them against the potential reduction in future risk of aortic dissection.4–7,10–14 5.1.2.2 Intervention: Repair or Replacement of the Aortic Valve Recommendations for Intervention: Repair or Replacement of the Aortic Valve Referenced studies that support the recommendations are summarized in Online Data Supplement 18. COR LOE Recommendations 2b C-LD 1. In patients with BAV and severe AR who meet criteria for AVR, aortic valve repair may be considered in selected patients if the surgery is performed at a Comprehensive Valve Center.1–3 2b B-NR 2. In patients with BAV and symptomatic, severe AS, TAVI may be considered as an alternative to SAVR after consideration of patientspecific procedural risks, values, trade-offs, and preferences, and when the surgery is performed at a Comprehensive Valve Center.4–6 Synopsis The indications for the timing of aortic valve intervention in patients with a BAV and AS or AR is similar to those for trileaflet aortic valves. See the respective sections on AS (Section 3.2) and AR (Section 4). The choice of prosthetic valve type in patients with a BAV is similar to that for patients with trileaflet valves. See the section on prosthetic valve choices (Section 3.2.4.1) for full details. Given the unique nature of BAV, however, there are additional specific considerations. Recommendations for Intervention: Replacement of the Aorta in Patients With a BAV (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026