Unintended Impact of Left-Shifting Aortic Guidelines on Aortic Valve Interventions

BACKGROUND: This study examines the impact of lowering size threshold for intervention of aortic root or ascending thoracic aortic aneurysm (ATAA) on the fate of the aortic valve. METHODS: The Treatment in Thoracic Aortic aNeurysm: Surgery vs Surveillance (TITAN:SvS) surgical registry is a multicenter prospective registry of patients who underwent surgery for ATAA between 5.0 and 5.4 cm at expert aortic centers. Echocardiographic, procedural, and outcome data were prospectively collected. Multivariable analyses examining predictors of aortic valve replacement (AVR) included demographic, preoperative (aneurysm location and size), and echocardiographic (valvular disease severity and valve morphology) characteristics. RESULTS: From October 2021 to June 2025, 369 patients from 22 centers were included. The mean age of the cohort was 62.2 ± 11.7 years, and 22.2% (n = 82) were female. AVR was performed in 35.5% (n = 131), of whom 26.7% (n = 35) had severe aortic valve disease and 24.2% (n = 31) had no or mild aortic valve disease. Of the 174 patients who underwent root replacement, 64.9% (n = 111) underwent valve-sparing root replacement, whereas 33.4% (n = 59) received composite valve and root replacement, of whom 89.8% (n = 53) had less than severe valvular disease and 27.1% (n = 16) had no or mild aortic valve disease. On multivariable analysis, after accounting for valvular disease severity, the presence of bicuspid aortic valve was an independent predictor for AVR (odds ratio, 2.4; CI, 1.4-4.1). CONCLUSIONS: Earlier intervention on ATAAs has the unintended effect of earlier AVR, particularly for those with preoperative aortic valve disease and bicuspid aortic valve. These findings should inform the timing of surgery and shared decision-making between physicians and patients.