Ascending aortic growth and risk of aortic sissection or reintervention after valve replacement in bicuspid and tricuspid aortic valve disease: a systematic review and meta-analysis
J Fernandes Pedro, A R M Figueiredo, C Sousa, F J Pinto, D CaldeiraAbstract
Background
Bicuspid aortic valve (BAV) disease has long been considered a substrate for accelerated aortopathy, characterized by earlier valvular degeneration and progressive enlargement of the thoracic aorta. Whether this presumed intrinsic aortic vulnerability persists after aortic valve replacement remains unclear. Comparative data between BAV and tricuspid aortic valve (TAV) populations following valve intervention are heterogeneous and have not been comprehensively synthesized. Therefore, a systematic review and meta-analysis was performed to evaluate postoperative aortic growth and major aortic complications after valve replacement in BAV versus TAV patients.
Methods
A systematic search of MEDLINE, CENTRAL and Web of Science, covering the period from database inception to April 2025, was performed to identify prospective and retrospective cohort studies enrolling adult patients with BAV or TAV undergoing surgical (SAVR) or transcatheter (TAVI) aortic valve replacement. Eligible studies were required to report longitudinal measurements of aortic growth rate (mm/year) and/or the occurrence of aortic dissection or aortic reintervention. Studies involving concomitant aortic surgical repair were excluded. Random-effects meta-analytic models were applied to estimate mean differences (MD) and risk ratios (RR), along with 95% confidence intervals (CI).
Results
Fifteen studies met inclusion criteria. Quantitative synthesis included 1,772 patients for aortic growth rate analysis, 2,307 for aortic dissection, and 2,598 for aortic reintervention. Across studies, annual aortic growth rate following valve replacement did not significantly differ between BAV and TAV patients (MD 0.15 mm/year; 95% CI −0.03 to 0.33; p = 0.09, I² = 82.6%). Meta-regression confirmed that age disparities between BAV and TAV cohorts were not associated with any modification of the overall neutral effect on aortic growth. Subgroup analyses yielded consistent results across study designs, although modest differences were observed according to procedure type (SAVR: MD 0.21 mm/year, p=0.07; TAVI: MD −0.04 mm/year, p=0.53; p=0.02 for interaction between SAVR and TAVI). Regarding clinical events, pooled analyses revealed no statistically significant differences in the risk of aortic dissection (RR 1.34; 95% CI 0.63–2.83; p = 0.44) or need for future aortic reintervention (RR 0.95; 95% CI 0.56–1.61; p = 0.84).
Conclusions
Aortic expansion and event rates after valve intervention were comparable between BAV and TAV patients. These findings challenge the long-standing assumption that bicuspid morphology–associated pathophysiological mechanisms intrinsically drive accelerated postoperative aortic disease across all patients.Figure 1