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Objectives: Different methods to classify the anatomical configurations of the aorta with bicuspid aortic valve (BAV) have been proposed. We aimed to test them in terms of descriptive power (i.e. capability to identify different clusters of patients with unique associations of anatomo-clinical features) and possible prognostic significance. Methods: A consecutive echocardiographic series of 696 BAV patients (mean age 48 ± 16 years, male:female ratio 3:1) was analysed. Three possible schemes for classification of the patterns of aortic dimensions were compared. One defined the aortic shape as 'N' (ascending < sinuses > sinotubular junction (STJ)), 'A' (ascending > sinuses > STJ) or 'E' (sinotubular ≥ sinuses), the second as 'non-dilated', 'ascending phenotype' (dilated, with ascending > sinuses) or 'root phenotype' (dilated, with sinuses > ascending) and the third as normal, 'type I' (dilated only at the ascending tract), 'type II' (dilated at both ascending and sinus levels) or 'type III' (dilated only at the sinuses). We evaluated the correlation with valve morphotypes (right-left fusion, right-non-coronary fusion) and patient characteristics. In a smaller longitudinal study (n = 150), the occurrence of fast growth of the aorta (fifth quintile: ≤1 mm/year) during follow-up (5 ± 3 years) in the various phenotypes was assessed. Results: The three classification methods proved meaningful in terms of association with valve morphotypes: significant associations were found between right-left-coronary BAV and the root phenotype (P < 0.001) and between the right-non-coronary BAV and the shapes A and E (P1 mm/year) of the ascending diameter (50% root phenotype patients; P = 0.005). The association with the N type was weaker (P = 0.055); no association was found with types from the other classification scheme (P = 0.42). Conclusions: When tested on a large population, three previously suggested phenotypic classifications of the BAV aorta proved to categorize patients into significantly different clusters, but only the classification system distinguishing between ascending phenotype and root phenotype showed a potential prognostic value. Phenotypic class of the aorta could be a factor to integrate in future comprehensive models for risk stratification of BAV aortopathy. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

AIMS Age over 75 years and logistic Euroscore over 20% have been jointly proposed by European scientific associations as the criteria for aortic valve stenosis patients to be considered 'high-risk' for surgical aortic valve replacement (AVR) and candidates for transcatheter aortic valve implantation (TAVI). We aimed to verify traditional AVR outcomes in the presence of the above criteria. METHODS Between January 2001 and January 2011, 180 patients with severe aortic valve stenosis (mean aortic valve area = 0.4±0.1 cm/m), with age range 75-88 years (mean 78.2±3), logistic Euroscore between 4.5 and 40% (mean 12.6±7.4%), underwent surgical AVR. The patient population was divided into group A (118 patients between 75 and 79 years of age), further divided into subgroups A1 (76 patients) and A2 (42 patients) with logistic Euroscore, respectively, less than 20% and at least 20%; and group B (62 patients between 80 and 88 years of age), subdivided into B1 (34 patients) and B2 (28 patients) with logistic Euroscore, respectively, less than 20% and at least 20%. Hospital outcomes were retrospectively evaluated. Univariate and multivariate analyses, including age and logistic Euroscore, were performed to individuate predictors of hospital mortality. RESULTS Overall observed/expected mortality ratio was 0.4. Hospital mortality was 5.3% in group A1, 4.8% in A2, 5.9% in B1, 3.6% in B2 (P=NS). Mortality with age over 75 and Euroscore at least 20% was 4.3%. As regards postoperative morbidity, atrio-ventricular bock indicating pacemaker implantation occurred in four patients, pneumonia in three, stroke in two, perioperative myocardial infarction in one. Age and Euroscore were not independent predictors of mortality, morbidity or composite endpoint in multivariable analysis. CONCLUSION Age and logistic Euroscore might be inadequate criteria for the identification of patients with severe aortic stenosis unsuitable for AVR and addressable to TAVI.