Stenotic BAV/Aneurysm: What Is To Be Done?

With a bicuspid valve and an aortic aneurysm, the plan seems to be to replace the valve, preserve the aortic root if it is normal (and mine is,) and repair the aortic aneurysm. The reason that it is important to preserve the aortic root (the part of the aorta that connects to the heart) is because that's where the two coronary arteries branch off. If you have to replace everything...the valve, the aortic root, and the ascending aorta, the surgeon has to reconnect the two coronary arteries to the aortic root graft. This is called a "Bentall," or " Button Bentall" procedure and it is tricky and can lead to a lot of extra complications. Once again, getting things taken care of before the BAV disease leads to aortic root problems seems like a real good idea.

So, it will be interesting to see what the surgeon says on January 6. My "numbers" are borderline, I think. According to The American College Of Cardiology/American Heart Association Guidelines :

In patients with bicuspid valves undergoing AVR because of severe AS or AR (see Sections 3.1.7 and 3.2.3.8), repair of the aortic root or replacement of the ascending aorta is indicated if the diameter of the aortic root or ascending aorta is greater than
4.5 cm.*

If patients with bicuspid valves and associated aortic root enlargement undergo AVR because of severe AS or AR (Sections 3.1.7. and 3.2.3.8.), it is recommended that repair of the aortic root or replacement of the ascending aorta be performed if the diameter of these structures is greater than 4.5 cm (366).

So mine is a complicated situation. My AS is technically still in the moderate range with a valve area of 1.3 cm2, but adjusted for my body size it falls in the "severe" range (VAI = <.6). So, by itself, my valve problem is borderline by the numbers. My symptoms do not include the most serious manifestations of AV disease (dizziness and fainting,) rather I do experience exertional dyspnea and angina.

However, I do have a BAV and an aneurysm. Surgery is recommended to repair an anuerysm if the maximum diameter is 5.0 cm or more, or 4.5 cm if valve surgery is also being performed. My aneurysm is 4.3 cm, just under the recommended size for repair during AVR. Well, it makes no sense to me to have valve replacement surgery and not correct the aneurysm. Who wants to have to undergo another OHS later on to correct an aneurysm, or worse yet, experience an emergency related to the aneurysm?

So, what will the surgeon's recommendation be on January 6? Should I wait until the aneurysm grows and/or the valve stenosis gets worse, or more likely, both problems worsen? I could do that but that doesn't make a whole lot of sense to me either. I think that the combination of moderate to severe AS AND a BAV/aneurysm will trip the "surgery now rather than later" wire.

Therefore, my hunch is that the surgeon will recommend immediate AVR and ascending aneurysm repair.

Let's see if I'm right.