Aortic root replacement in a 50 year old patient with dilate | Figure 1

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Aortic root replacement in a 50 year old patient with dilated root & bicuspid aortic valve disease. They had an anomalous left circumflex artery, arising from the right coronary ostium & traveling around the back of the aortic root (arrows).

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echo depicting a bicuspid aortic valve vegetation (blue arrow) with aortic root abscess (red arrow) . Group B strep endocarditis. Very prominent aortic regurg murmur heard on exam.](https://app.figure1.com/case-detail/08327869-6a5c-4a86-a7cb-50a64e08551b)

Dilated aortic root and ascending aorta](https://app.figure1.com/case-detail/0a943454-fac1-4756-bc2c-435b031e5335)

#Manouguian procedure for #aortic root enlargement. Patient required aortic valve replacement however it was not possible to fit a prosthetic valve large enough for the patient's body size. The aortic annulus was enlarged by extending the cut in the aorta down between the left & non-coronary cusps into the fibrous tissue of the subaortic curtain. A patch of bovine #pericardium was used to reconstruct the defect.](https://app.figure1.com/case-detail/203ccc9c-d9f4-4936-bc9b-dd261035748d)

Heterogeneity is the rule with bicuspid aortic valves, so optimal surgical solutions vary by patient. Our experts share experience-based guidance for managing various presentations of bicuspid aortic valve and aortopathy: If the valve is the primary indication for surgery (i.e., severe aortic stenosis and/or severe regurgitation):\

1. Replace the aorta if >45 mm in diameter.\
2. Replace the root too if it is >5 cm and AVR is being done. If the native valve is being retained, it needs to be stabilized, so the diameter threshold should be lowered to >45 mm.\
3. Sometimes thresholds need to be lowered further, depending on the quality of tissue or for a small patient, such as an individual with Turner syndrome or other syndromic connective tissue disorder. If the aorta is the primary indication for surgery:\
4. Operate if the aorta is >5 cm in diameter or the cross-sectional area-to-height ratio is >10 cm2/m.\
5. Consider sparing the valve if it looks healthy, but address the root if >45 mm.\
6. Selectively lower thresholds.\
7. In some cases, parts of the arch should be resected because this may be curative.](https://app.figure1.com/case-detail/23eeb6fb-7290-4070-9a72-9e2fd51412f5)