Bicuspid versus tricuspid aortic valve morphology in elective ascending aortic aneurysm surgery: A propensity score-matched analysis.

OBJECTIVE

To compare perioperative and long-term outcomes between bicuspid (BAV) and tricuspid (TAV) aortic valve patients undergoing elective ascending aortic aneurysm surgery using propensity score matching (PSM).

METHODS

We retrospectively analyzed 1340 consecutive adults who underwent elective ascending aortic surgery for aneurysm at a single high-volume center between January 2014 and December 2025. After exclusions, 816 patients (373 BAV, 443 TAV) were eligible. PSM (1:1 nearest-neighbor, caliper width 0.2 SD on the logit scale; 14 baseline covariates, including ascending aortic diameter) produced 285 matched pairs (all with standardized mean difference <0.10). Primary endpoints were 30-day and 10-year all-cause mortality; secondary endpoints included early postoperative complications and late aortic reintervention.

RESULTS

The median follow-up was 5.4 years (interquartile range, 2.6-8.1; completeness, 96.7%). Thirty-day mortality was 0.7% (n = 2 of 285) in the BAV group versus 1.05% (n = 3 of 285) in the TAV group (odds ratio, 0.66; 95% confidence interval, [CI], 0.11-3.98; P = 1.00). Ten-year survival was 61.4% (95% CI, 55.8%-67.1%) in the BAV group versus 57.9% (95% CI, 52.2%-63.6%) in the TAV group (log-rank χ2 = 2.39; df = 1; P = .31). Early postoperative complications did not differ between the 2 groups (all P > .05). The cumulative incidence of late aortic reintervention at 10 years was 4.6% (95% CI, 2.1%-8.5%) in the BAV group versus 3.5% (95% CI, 1.4%-7.0%) in the TAV group (Gray test, P = .57). In multivariable Cox regression, BAV morphology was not an independent predictor of mortality (hazard ratio, 0.92; 95% CI, 0.58-1.45; P = .74).

CONCLUSIONS

In this propensity score-matched cohort, BAV morphology was not associated with worse perioperative or long-term outcomes after elective ascending aortic surgery compared to TAV. These findings support managing BAV-related aortopathy according to the same patient- and anatomy-driven principles used for TAV rather than based on valve morphology alone.