Bicuspid Surgical Aortic Valve Replacement: Anatomical Insight, Medium Term 5 Years Outcomes, and Predictors of Mortality: An Echocardiographic Study

Background/Purpose Bicuspid aortic valves (BAV) are a common cause of surgical aortic valve replacement (SAVR). This study aims to evaluate medium‐term (5‐year) outcomes, echocardiographic changes, and predictors of mortality in bicuspid SAVR patients, with a focus on preoperative and postoperative echocardiographic parameters, including strain measurements. Methods A retrospective cohort of 448 bicuspid SAVR patients from 2015–2021 was analyzed. Preoperative echocardiograms were obtained within 1 month before surgery, with follow‐up at 6 months. Parameters assessed included standard measurements (e.g., stroke volume index [SVi], ejection fraction [EF], flow rate, and pressure gradients) and advanced strain metrics (e.g., global longitudinal strain [GLS], left atrial reservoir strain [LArS], and right ventricular free wall strain [RVFWS]). Mortality data were collected via national registry, with a median follow‐up of 54.2 months. Results The median age was 59 years; 68.5% were male. The 30‐day and 5‐year mortality rates were 3.6% and 18.3%, respectively, both lower than the overall SAVR cohort. Preoperative parameters such as lower SVi ( p = 0.027), EF ( p = 0.045), flow rate ( p = 0.027), and reduced strain measures (LArS, p < 0.001; LAcS, p = 0.013; RVFWS, p = 0.005) correlated with worse outcomes. Postoperative reductions in EF and SVi were observed, but only the change in mean pressure gradient (meanPG) was associated with 5‐year mortality. Higher absolute LArS independently predicted improved survival ( p < 0.001). Multivariate analysis identified hypertension, elevated urea, longer hospital stays, and higher preoperative LArS as independent predictors of mortality. Conclusions Bicuspid SAVR patients exhibit favorable medium‐term survival, with 5‐year mortality at 18.3%. Absolute preoperative LArS are a key independent predictor of outcomes, alongside clinical factors such as hypertension and urea levels. The reduction in meanPG postsurgery correlates with better long‐term survival, emphasizing the importance of comprehensive echocardiographic assessment in risk stratification and management.