Study population and follow-up
A retrospective review of our Institutional, prospectively maintained, database was carried out to identify patients with BAV and mild to moderate aortic regurgitation who underwent elective ascending aorta replacement from June 2002 to January 2020. Patients with acute aortic dissections and aortic root pathology were excluded. Bicuspid aortic valve morphology was preoperatively characterized by means of trans-thoracic or trans-esophageal echocardiography and subsequently intraoperatively confirmed. Patients charts were then analyzed to obtain details about pre-operative characteristics, intra-operative variables and in-hospital outcomes. All operations were performed using conventional cardio-pulmonary by-pass and mild hypothermia through a median sternotomy. The final decision to preserve the BAV was taken intraoperatively by the operating surgeon according to the degeneration degree of the aortic leaflets. Usually the native BAV was preserved because the leaflets appeared relatively free from fibrosis or calcification. The size of the aortic vascular graft, and the subsequent degree of sino-tubular junction (STJ) remodeling, was decided by the operating surgeon according to the anatomical finding. In case of moderate aortic regurgitation, type Ia according to the El-Khoury classification8, a smaller graft was employed to restore a more physiological annulus/STJ ratio and decrease the grade of aortic regurgitation. Transesophageal echocardiography was performed after weaning from the CPB to assess the BAV function. Survival and echocardiographic follow-up were carried on querying the informatic hospital system for out-patients visit and echocardiographic examinations. If follow up information were not present in the hospital system, patients were reached via phone call or the referring cardiologist was contacted. The Ethical Committee of our Institution approved the study and individual informed consent for this retrospective analysis was not requested.