Diameter-based decision making in bicuspid aortic valve aortopathy: is it time to expand our perspective?

Bicuspid aortic valve (BAV) and the associated aortopathy (BAVA) are remarkably commonplace; the former is the most common congenital heart anomaly occurring in 1–2% of the general population and aortic dilatation to a greater or lesser degree is present in 30–60% if not more (1). Guidelines for ascending aortic intervention (AAI) to prevent acute aortic syndromes (AAS) have been established and recommend aortic replacement when aortic diameter exceeds 55 mm (Class I), at 50 mm when other factors such as family history, expansion rate are present, (Class IIa), or when the patient is low operative risk at a center with established expertise (Class IIa), or at 45 mm if concomitant aortic valve replacement is planned (Class IIa) (2). Despite these size-based guidelines, still there is controversy in the literature and, more importantly, in practice, with intervention occurring over one-third of the time in BAVA patients with diameters less than 45 mm (1).