Management of Bicuspid Aortic Valve Aortopathy: To Perform or Not to Perform Circulatory Arrest

Purpose: Equipoise persists regarding the extent of surgical resection in bicuspid aortic valve aortopathy. We desired to determine if initial postoperative ventilator hours or hospital length of stay differed between open hemiarch and clamped distal anastomosis cohorts. Methods: Patients with a bicuspid aortic valve undergoing elective or urgent first-time ascending aortic replacement at a single institution from July 2020 to December 2024 were retrospectively reviewed from a prospectively maintained database. Primary outcomes of interest were survival to hospital discharge, duration of postoperative ventilation, and hospital length of stay. We additionally compared rates of postoperative transfusion, stroke, and unplanned reoperation. Patients with bicuspid aortopathy were divided into two cohorts: open anastomosis under circulatory arrest versus clamped distal anastomosis and matched 1:3 based on a 10 covariate propensity score. Results: Over the study period, 148 patients with bicuspid aortopathy underwent first-time ascending aortic replacement. After matching, there was no significant difference in survival to discharge among patients undergoing circulatory arrest (96% vs. 100%, p = 0.29). Median duration of postoperative ventilation was significantly higher among patients undergoing open hemiarch anastomoses (8.0 h vs. 5.2 h, p = 0.001). Postoperative length of stay was one day longer in the open hemiarch group, but did not meet statistical significance (8.9 vs. 7.8 days, p = 0.18). There were no significant differences in major complications between groups. Conclusions: Bicuspid aortopathy patients undergoing open hemiarch anastomoses had a significantly longer duration of postoperative ventilation without any difference in morbidity or mortality. The approach to ascending aortic replacement among patients with bicuspid aortic valves remains a highly individualized decision, relying on surgeon experience and anatomic factors.