Growth rate of the ascending aorta and risk of aortic dissection or reintervention in patients with bicuspid or tricuspid aortic valves undergoing valve interventions: A systematic review and meta-analysis.

BACKGROUND

Bicuspid aortic valve (BAV) is associated with premature valve dysfunction and progressive aortic dilation, potentially leading to dissection. The evolution of aortic dimensions after valve replacement remains uncertain, particularly compared with tricuspid aortic valve (TAV) disease. This systematic review and meta-analysis aimed to compare postoperative aortic growth and the risk of major aortic events between BAV and TAV patients.

METHODS

A systematic search of MEDLINE, CENTRAL, and Web of Science (from inception to April 2025) identified prospective and retrospective cohort studies including adult patients with BAV or TAV undergoing surgical (SAVR) or transcatheter (TAVI) aortic valve replacement. Studies were required to report longitudinal data on aortic growth rate (mm/year) or the incidence of aortic dissection or reintervention; those with concomitant aortic surgery were excluded. Random-effects meta-analyses estimated mean differences (MD) and risk ratios (RR) with 95% confidence intervals (CI).

RESULTS

Fifteen studies were included (n=1772 for aortic growth; n=2307 for aortic dissection; n=2598 for aortic reintervention). There was no significant difference in annual aortic growth between BAV and TAV (MD 0.15 mm/year; 95% CI -0.03 to 0.33; p=0.09; I2=82.6%). Meta-regression confirmed that age differences between BAV and TAV cohorts did not modify the overall neutral effect on aortic growth rate. Subgroup analyses showed similar findings across study designs, but small differences in procedure types (SAVR MD 0.21 mm/year, p=0.07; TAVI MD -0.04 mm/year, p=0.53; p=0.02 for SAVR vs. TAVI differences). No significant differences were found in the risk of aortic dissection (RR 1.34; 95% CI 0.63-2.83; p=0.44) or aortic reintervention (RR 0.95; 95% CI 0.56-1.61; p=0.84).

CONCLUSIONS

Postoperative aortic growth and event rates were comparable between BAV and TAV patients after valve replacement. These results challenge the long-standing assumption that bicuspid morphology intrinsically accelerates postoperative aortopathy in all patients.