Left ventricular reverse remodeling after aortic valve replacement or repair in bicuspid aortic valve with moderate or greater aortic regurgitation

Objective Bicuspid aortic valve (BAV) patients with aortic regurgitation (AR) differ from tricuspid AV patients given younger age, greater LV compliance, and more prevalent aortic stenosis (AS). BAV-specific data to guide timing of aortic valve replacement or repair (AVR/r) is lacking. Methods Adults with BAV and ≥moderate AR who underwent AVR/r at our center were studied. The pre-surgical echocardiogram, and echocardiograms within 3-years post-operatively were evaluated for LV geometry/function, and AV function. Semi-quantitative AS/AR assessment was performed in all patients with adequate imaging. Results 135 patients (85% male, 44.5±15.9 years) were studied (63% pure AR, 37% mixed AS/AR). Following AVR/r, ΔLVEDd and ΔLVEDV were associated with pre-operative LVEDd (β = 0.62 Δcm/cm, 0.43-0.73, p<0.001), and LVEDV (β = 0.6 Δml/ml, 0.4-0.7, p<0.001) respectively, each independent of AR/AS severity (p=NS). Baseline LV size predicted post-operative normalization (LVEDd: OR 3.75 per cm, 1.61-8.75| LVEDV: OR 1.01 per ml, 1.004-1.019, both p<0.01) whereas AR/AS severity did not (p=NS). LVEDVi outperformed LVEDd in predicting post-operative LV normalization (AUC 0.74 vs 0.61) with optimal diagnostic cutoffs of 99ml/m2 and 6.1cm, respectively. Post-operative LVEDVi dilatation was associated with increased risk of death, transplant/VAD, ventricular arrhythmia, and reoperation (HR 6.1, CI 1.7-21.5, p<0.01). Conclusions Remodeling extent following surgery in BAV-AR relates to pre-operative LV size independent of valve disease phenotype or severity. Many patients with LVEDd below current surgical thresholds did not normalize LV size. LV volumetric assessment offered superior diagnostic performance for predicting residual LV dilatation, and post-operative LVEDVi dilatation was associated with adverse prognosis.