Guidelines for management of bicuspid aortic valve aneurysms: what's the clinician to do?

The timing of prophylactic ascending aortic aneurysm surgery in the setting of bicuspid aortic valve disease is complex, with multiple factors influencing the decision. The 2014 ACC/AHA Valve guidelines recommend prophylactic replacement of the aortic root and/or ascending aorta once the aortic diameter exceeds 5.5 cm. This aortic size threshold for surgery is at a larger diameter than had been recommended by the 2010 Thoracic Aortic Disease guidelines, the 2013 Society of Thoracic Surgeons Clinical Practice Guidelines, or the 2006 ACC/AHA Valve guidelines. Five recent societies or committees recently published their guidelines to assist with managing these cases. Making the decision regarding the timing of bicuspid aortic valve aneurysm surgery even more difficult are the small, but important, differences in recommendations provided among recent guidelines addressing this issue.