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Removing the bicuspid source of aortopathy prevents further dilatation.

We read with interest the article by Vendramin et al. in which they reviewed 166 consecutive patients with bicuspid aortic valve (BAV) who underwent ei-ther the Bentall procedure or aortic valve replacement (AVR) with supracoro- nary ascending aorta replacement (SAAR) [1]. They found no progressive dilatation of the native aortic root in the SAAR group, regardless of whether the preoperative root diameter was < 40 or > 40 mm, with a mean follow-up of 73 6 39 months. Although bearing a number of limitations such as small sample size, limited follow-up and no data on the morphology of BAV cusp fusion, their results show positive correlation with our group’s data on 5-year follow-up of remaining aorta dilatation after AVR or aortic root replacement (ARR) in patients with BAV [2]. We analysed 395 (192 BAV, 203 tricuspid aortic valve) patients who underwent AVR or ARR. An ascending aorta/root diameter of (cid:2) 45 mm was an indication for Bentall procedure. We found no signiﬁcant dilatation of the remaining ascending aorta or arch after AVR or ARR at 5 years.These results lend further weight to the haemodynamic explanation of BAV- related aortopathy. The thoracic aorta experiences highly variable ﬂow char-acteristics, where the morphology of the aortic valve can signiﬁcantly impact the velocity and symmetry of blood ﬂow in the aorta [3]. Aneurysm formation is greatly affected by haemodynamic factors, and a number of biomechanical forces have been the subject of intense research in linking BAV morphology with aneurysm formation. Wall shear stress (WSS) is the force per unit area exerted by a