I was pleased to read the report by McKellar et al that in patients with bicuspid aortic valves, the occurrence of aortic dissection was low after aortic valve replacement, and aortic dilatation did not predict mortality. The investigators concluded that there was “scant evidence for prophylactic replacement of the ascending aorta” at the time of aortic valve replacement.

These results support a 2008 report in this journal that criticized the American College of Cardiology and American Heart Association practice guidelines, which recommended prophylactic aortic replacement on the basis of experience with the Marfan syndrome, a genetic disorder with proved weakness of connective tissue. Most of the surgical procedures they cited reported leaving the bicuspid aortic valves in place, which is unwarranted because of the likelihood of progression of aortic regurgitation.

McKellar et al ¹ concluded that the risk for “prophylactic” aortic replacement should be no greater than the risk for dissection; the risk for dissection in their 1,286 patients over a follow-up period of 12 years was only 1%. My 2008 report ² summarized publications from 5 major centers and found that aortic replacement without valve replacement had an average mortality of 4% acutely, and late mortality was 10%! McKellar et al ¹ were unnecessarily restrained in their conclusion concerning prophylactic aortic replacement.