Hi Maso.
My bicuspid aortic valve has progressed into the severe category,
From a previous post you indicated that you are dealing with stenosis and not regurgitation, so when you say your BAV has progressed to severe, I'll assume that you mean that your aortic stenosis is now severe.
I consulted with a surgeon following my cardiologist's update that it's likely time for intervention (July)
Good. Once your AS is severe it is best not to delay.
my aortic aneurysm measures 4.1
the surgeon said open-heart surgery (OHS). However, she mentioned that my aneurysm isn't yet at the 'clinical' size for repair.
Would the surgeon still address the aneurysm during the same procedure, even if it's not yet at the recommended size for repair?
This is a good question. Since you will already be undergoing OHS, it makes sense to want to get the aneurysm repaired while they have you opened up. However, she is correct that your aneurysm is not yet at the clinical size yet for repair. They do lower the threshold for repair if they are going in for valve surgery anyway. To my knowledge the lowered threshold to repair the aneurysm for BAV patients receiving SAVR is 4.5cm, so you are still below this lowered threshold. I have linked a study below with a lot of good data and which discusses this specific issue, and supports the 4.5cm threshold with data.
However, having an aneurysm below the threshold for repair does not necessarily mean that this is the end of the discussion, as there is room for the expert opinion of the surgeon at the time of surgery.
@Beach77 mentioned that I had an aneurysm repaired during my SAVR, so let me quote him and clarify a couple of points:
@Chuck C was able to get his aneurysm repaired, his surgery was a few months after mine, and I believe his aneurysm size was just under the recommended size for repair too. He was able to request the doctor repair it during his surgery and he did, because he knew Chuck really wanted it repaired.
Yes, I did have my aneurysm repaired which was below the guidelines. In fact, it was well below the guidelines at 3.6cm, but it was not done at my request. Getting the aneurysm repaired was not even on my radar going into my surgery.
However, when my surgeon got his eyes on my aortic tissue during surgery, from his decades of experience, he recognized that I appeared to have the aortic connective tissue disorder which very often accompanies BAV, and can lead to future repair. He made a judgement call on the spot. But, there is more to his judgement call that I should detail, so I'll give a little more back story to give context as to why he made the decision that he did.
5 months earlier, while still in the moderate AS category, I had my first consult with my surgeon. At the time I expressed my desire to go with a tissue valve. Once I crossed the line into the severe category, 4 months after that first consult, I consulted with him again. At this second consult I informed him that I had changed my mind and wanted to go with a mechanical valve. At age 53 I had played out the number of future OHS I would need and I didn't like it. I also was not keen on TAVI as a potential for intervention on round 2, which seems to be more of a band aid suited for those who are high risk patients, given it's uncertain duration and uncertain outcomes for young patients. I told him that I wanted to be "one and done". We spoke for about an hour during each of my consults, so he knew my desires very well. These points are important, because he factored them into his decision on whether to make the aneurysm repair at the time of my valve surgery.
I learned more of what went into his decision when he visited me in ICU, two days after surgery, at which time he fully discussed what went into his decision. I will also say that he did not take the decision lightly. He could have gone either way. The deciding factor was that he knew my strong desire to be one and done. He even had his assistant get my wife on the phone before he proceeded with the aortic repair, because he wanted to get her blessing. When my wife got the call, they had just told her in the waiting room that surgery should be wrapping up soon and if she needed to go to the cafeteria to get lunch this would be a good time. Well, that was when she got the call from the operating theater. She couldn't hear the surgeon, as the cafeteria was noisy and asked him if he could wait a minute for her to go outside to hear better. He said "No, I'm in the middle of open heart surgery on your husband and I can't wait a minute." He wanted her blessing, but ultimately he had to make the call and decided to go forward with the repair.
His decision was based on the following:
1. Experience: With his thousands of previous valve surgeries completed, his visual inspection of my aorta informed him that I appeared to have the connective tissue disorder which would cause my aneurysm to continue to enlarge.
2. His knowledge of his patient- me. He knew I was going mechancial to be "one and done" and would not want another OHS down the road for aneurysm repair.
3. Judgement. It really came down to combining his surgical experience with knowledge of his patient and making a decsion that he believed that I would have wanted him to make.
After discussing the issue with him after surgery, I told him that I believed he 100% made the right decision.
Please see the linked study below, which has lots of good data pertaining to this specific issue of whether to repair or wait.
"Borger and colleagues investigated the long-term aortic outcomes in BAV patients who had undergone isolated aortic valve replacement. Patients were grouped by the baseline ascending aortic size (< 4.0 cm, 4.0–4.5, and 4.5–4.9 cm) at time of valve surgery. Fifteen-year freedom from ascending aorta-related complications was 86, 81, and 43% in patients with an aortic diameter of < 4.0, 4.0–4.4, and 4.5–4.9 cm, respectively (
P < 0.001), suggesting concomitant replacement of the ascending aorta is warranted if the diameter is 4.5 cm or greater at time of aortic valve intervention"
Also:
"With the current evidence and due to the considerable heterogeneity described, the surgical threshold for borderline lesions remains largely at the surgeon’s discretion despite practice guidelines. "
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525390/
So, as so often is the case, surgical opinions will vary in your situation. Some will not touch the aorta if it is not yet at the exact size called for in the guidelines. Others might take their experience into account and could decide to repair sooner if they believe the situation warrants it.
At 60 I would expect that you are probably considering going with either a tissue valve or a mechanical valve. If you decide to go tissue, that could come into play as well, and might tilt the scales towards not repairing at this time. At 60, you will likely need another OHS in future years, if you go tissue, so this would potentially give another opportunity to make an aortic repair, should your aneurysm continue to grow.
