The prognosis of aortic valve diseases with ascending aortic aneurysms (AAA) varies according to the underlying etiology. The surgical strategy often depends on the aortic valve disease. Procedures include supracoronary ascending aorta replacement (AAR) with aortic valve replacement (AVR) and composite aortic valve graft replacement (Bentall-De Bono). It is often believed that the aortic aneurysm seen along with degenerative aortic stenosis is due to post-stenotic dilatation^[1^]. Valve intervention is necessary when aortic regurgitation is seen along with AAA. In the past, supracoronary AAR with AVR or composite aortic valve graft replacement was commonly used for these patients. In recent years, valve-sparing aortic root replacement surgery is preferred in aortic root dilatation with normofunctional valves. Performing AAR+AVR in patients with bicuspid aortic valve (BAV) do not completely remove the underlying pathology, since the defect remains in the tunica media of the aorta. The aim of this study is to investigate the change in the dimension of sinus of Valsalva in patients who underwent supracoronary AAR together with AVR.

Operative data are shown in Table 2. The aortic valve was replaced by a tissue valve in 4 (4.9%) patients, and a mechanical valve in 77 (95.1%) patients. The mean size of the replaced valve was 23.50±1.6 mm. All patients received a Dacron graft with a mean size of 29.3±1.6 mm.

There are a number of surgical strategies for patients with AAA and concomitant aortic valve diseases. When aortic root aneurysm is present, Bentall-De Bono surgery is preferred, while AVR and supracoronary AAR is used in patients with AAA and aortic valve pathologies without annular or sinus dilatation^[2^,3^]. The operative outcomes of supracoronary AAR with AVR are excellent and there is no additional risk in elective and non-high-risk patients^[4^]. The aetiology of valvular disease, intraoperative shape and ascending aortic wall thickness and the patient's condition are important factors for surgical decision in BAV^[5^].

AAA seen in aortic stenosis of calcific degeneration is usually post-stenotic dilatation. It is progressive and its rate of increase is reported to be >3 mm/year^[1^]. If aortic valve and ascending aorta were replaced in these patients, the underlying pathology would be cured. In our study, 30 patients had aortic stenosis caused by calcific degeneration. Regarding the sinus of Valsalva diameter, the postoperative diameter, compared to the preoperative size, did not change significantly (P>0.05). In AAA with aortic valve insufficiency, the sinus of Valsalva diameter is also enlarged. With progression of AAA, dilatation of the sinotubular junction, displacement of commissures, distortion or dilatation of one or more sinus of Valsalva, annuloaortic ectasia alone or in combination can cause aortic regurgitation. In our study, 24 patients underwent AAR+AVR due to aortic regurgitation and AAA. The postoperative sinus of Valsalva diameter, compared with preoperative size, was not significantly different (P>0.05). Although sinus of Valsalva was dilated preoperatively in some patients, composite valve-graft replacement or valve-sparing aortic root replacement was not performed. These operations may have been avoided because of the patients' advanced age.

BAV is not just a valvular disease, but a component of a wider pathology also including the ascending aorta^[6^]. Although tunica media and normal aortic valve in BAV is the same, the gap between elastic lamella is greater. Patients with BAV have thinner elastic lamellae of the aortic medium than patients with tricuspid aortic valve^[7^]. Fibrillin-1 is a glycoprotein needed for structural continuity of aortic wall and valves. Fibrillin-1 deficiency is more common in BAV compared with that seen in tricuspid aortic valves^[8^]. Higher activity of proteolytic enzymes known as matrix metalloproteins was seen in aortic aneurysms associated with BAV when compared to aneurysms of patients with tricuspid valves^[9^]. High tension and shear stress play an important role in the pathogenesis of ascending aortic aneurysm with BAV. Tensile stress is the force perpendicular to the aortic wall, and increases with aortic diameter according to the law of Laplace. On the other hand, shear stress is a product of blood viscosity and velocity and is a force parallel to the aortic wall causing friction to the endothelial surface^[6^]. Current guidelines suggest the replacement of the ascending aorta in the presence of a diameter of 50 mm or more, if associated with BAV disease with additional risk factors or coarctation^[5^].

In our study, AAR+AVR was performed in 17 patients with BAV and AAA. Postoperative sinus of Valsalva diameter, compared with the preoperative size, was significantly increased in these patients (P<0.01). The follow-up period of these patients was 46.59±12.64 months.

The relationship between follow-up duration and sinus of Valsalva diameter was not statistically significant. It could be due to a small numbers of patients and shorter follow-up in some patients. An increase of 5±4.63 mm in sinus of Valsalva diameter was noted in this short follow-up. Longer follow-up duration in a larger group of patients could have revealed a significant increase in sinus of Valsalva diameter because the disease is progressive. Although the evolution of the ascending aorta with BAV is well documented in many studies^[10^,11^], the risk of progressive sinus of Valsalva dilatation is less clear. Vendramin et al.^[12^] showed that no progressive sinus Valsalva dilatation is recorded in the long-term follow-up. Conversely, a significant reduction of the mean aortic root diameter was observed in some patients.

According to Yasuda et al.^[13^], BAV replacement, either by stenosis or failure, did not prevent the progressive dilation of the proximal aorta, which differs from that observed in patients with tricuspid aortic valve.

Russo et al.^[14^], when following-up more than 100 patients undergoing AVR, also reported a higher incidence of sudden death and aortic dissection in a group of patients with BAV, a significantly larger increase in aortic diameter in the same group, suggesting that prophylactic surgery for replacement of the ascending aorta concomitant with valve replacement should be performed, even in the presence of mild dilation of the ascending aorta.

Borger et al.^[15^], in a clinical retrospective study assessing the aortic complications in patients with BAV, concluded that patients with aortic diameter exceeding 45 mm should undergo combined surgery, or that is, AVR and replacement of the ascending aorta to avoid reinterventions due to vascular complications, either aneurysms and dissections of the ascending aorta. In another study, there were no late reoperations for aortic root dissection or rupture in 124 BAV patients who underwent AAR+AVR during a follow-up of 75.2 months^[16^].

Study published by Etz et al.^[17^] reported that in cases of surgery due to aortic valve disease, associated with a diameter of the root or ascending aorta exceeding 4.0 cm and life expectancy greater than 10 years, the option was to replace both the valve and the aorta.

Some studies have shown that sinus of Valsalva aneurysm developed in long-term follow-up of patients who underwent AAR+AVR because of type A dissection^[18^,19^]. In our hospital, valve-sparing aortic root replacement or composite valve-graft replacement was performed in patients with type A dissection. That is the reason why we did not include these patients to our study.

In a study by Yun et al.^[20^], 49 of the 255 patients who underwent AAR+AVR were reoperated for aortic root pathologies. In a study by Houël et al.^[21^], the rate of freedom from second operation for aortic root pathologies was 97.3±1.9% in composite valve-graft replacement and 68.3±9% in AAR+AVR. It was stated that AAR+AVR was a risk factor for complications related to the aortic root. When these two studies were compared to our study, the rate of complications related to the aortic root was lower in our study. We included 71 patients and no patient was reoperated for aortic root pathologies in the medium-term follow-up. We assumed that this success was due to the choice of proper surgical technique and exclusion of dissection.

In patients with ascending aortic aneurysm and concomitant aortic valve diseases, the surgical technique should be selected according to the underlying disease. To avoid the risks associated with sinus of Valsalva dilatation, it is reasonable to replace the sinus of Valsalva in the setting of AVR and AAR for BAV with a dilated ascending aorta and relatively normal sinuses of Valsalva in young patients.