Bicuspid Aortic Valve with Aneurysm

A 52-year-old patient with severe shortness of breath, infective endocarditis, and a 50 mm ascending aortic aneurysm — treated by Dr. Vishal Khullar at Nanavati Max Super Speciality Hospital, Mumbai.

The following clinical profile was prepared in line with Indian medical confidentiality guidelines. The patient consented to publication of his case for educational and clinical record purposes. His identity has been withheld.

Patient identity withheld per confidentiality guidelines. Case published with documented consent.

Clinical Condition

The patient was diagnosed with three overlapping cardiac conditions, each of which carried independent surgical urgency. The combination made the case unusually complex.

The first finding was a bicuspid aortic valve, a congenital condition in which the valve has only two leaflets instead of the usual three. This abnormal structure had been present since birth, and over decades it had begun to fail mechanically. The second finding was an ascending aortic aneurysm measuring 50 millimetres, well above the 45 to 50 mm surgical threshold recommended by current cardiothoracic guidelines. Earlier imaging at the patient’s local hospital had estimated the aneurysm at 28 mm, indicating rapid progression. The third finding, and the most acute, was infective endocarditis affecting the aortic valve. Bacterial vegetations had destroyed parts of the leaflet tissue and the valve had begun to leak severely. Blood was flowing backward into the heart with every contraction.

Emotional and Psychological Impact

By the time the patient reached Mumbai, his breathlessness had become severe enough to limit ordinary movement around the house. The family described a period of considerable anxiety. They had visited a local hospital first, where a CT scan and echocardiography revealed the aortic leak. A relative referred them to Nanavati Hospital and to Dr. Vishal Khullar.

The family arrived without a clear understanding of what surgery would involve or what the recovery would look like. The diagnosis itself was difficult to accept, given that the patient had appeared otherwise healthy until the breathlessness began. The clinical team focused early consultations on patient and family education, recognising that informed consent for a procedure of this magnitude required time and clarity.

Pre-Surgical Assessment by Dr. Vishal Khullar

The patient underwent a complete cardiac and aortic workup before any surgical decision was made. The assessment was structured to clarify the severity of each condition and to establish whether a single combined operation was both feasible and safer than staged procedures.

• Transthoracic echocardiography to grade the severity of aortic regurgitation and to confirm the bicuspid morphology of the native valve.
• CT aortogram to measure the ascending aortic aneurysm and to map the aortic arch anatomy. Imaging at Nanavati Hospital documented the aneurysm at 50 mm, larger than the patient’s earlier scan suggested.
• Blood cultures and infection markers to confirm infective endocarditis and to identify the causative organism so antibiotic therapy could be directed appropriately.
• Coronary angiography to rule out concurrent coronary artery disease that might require simultaneous bypass grafting.
• Anaesthetic and renal fitness review, since the planned procedure involved deep hypothermic circulatory arrest and prolonged cardiopulmonary bypass.

Why a Combined Procedure Was Chosen

Several treatment paths were considered. Dr. Khullar’s team weighed the risks of staged surgery against a single combined operation. The combined approach was selected for the following clinical reasons.

• The aneurysm size of 50 mm carried a real risk of dissection or rupture. Delaying its repair to allow recovery from valve surgery would have left the patient in a high-risk window for several weeks.
• Active infective endocarditis required removal of the diseased valve along with any infected tissue surrounding it. Operating on the valve without simultaneously addressing the dilated aorta would have meant returning the patient for a second sternotomy within months, with significantly higher cumulative risk.
• A bicuspid valve combined with aortopathy is a recognised pattern in cardiothoracic surgery. Established consensus guidelines (American Association for Thoracic Surgery, 2018) recommend simultaneous repair of the valve and ascending aorta when the aneurysm exceeds 45 mm in patients undergoing valve surgery.
• The patient had adequate cardiac reserve and good organ function. He was a suitable candidate for the longer operating time and the period of circulatory arrest that the combined approach demanded.

The plan was finalised after a multidisciplinary discussion involving cardiac anaesthesia, perfusion, and intensive care teams. The patient and his family were counselled in detail about the planned circulatory arrest, the use of a vascular graft, and the prosthetic valve options.

Imaging confirmed the diagnostic triad. The illustration below summarises the anatomical findings observed on transthoracic echocardiography and CT aortogram.

Figure 1. Pre-operative anatomy showing bicuspid aortic valve with infective vegetations, ascending aortic aneurysm at 50 mm, and severe aortic regurgitation.

Step-by-Step Surgical Overview

• Median sternotomy was performed to access the heart and the ascending aorta.
• The patient was placed on cardiopulmonary bypass. Arterial cannulation was sited to allow selective antegrade cerebral perfusion during the period of circulatory arrest.
• Systemic cooling was initiated. The body was brought down to deep hypothermia to protect the brain and visceral organs against ischaemia.
• The aortic cross-clamp was applied. Cardioplegic solution was administered to arrest the heart in diastole.
• The diseased ascending aorta was opened. The bicuspid aortic valve was inspected and the infected leaflets and vegetations were excised. All visibly infected tissue was debrided to reduce the risk of recurrent endocarditis.
• Circulatory arrest: Body circulation was stopped for 24 minutes to allow safe excision of the dilated aortic segment. The brain and visceral organs are highly vulnerable to ischaemia during this window. Selective cerebral perfusion was maintained to protect neurological function throughout.
• A Dacron vascular graft was sutured into place to replace the aneurysmal segment of the ascending aorta. Distal and proximal anastomoses were tested for haemostatic integrity.
• A mechanical aortic valve prosthesis was implanted at the aortic annulus. The valve was tested intraoperatively for free leaflet motion and competent closure.
• Rewarming was initiated. Cardiopulmonary bypass was gradually weaned, and the heart was restarted in sinus rhythm.
• The chest was closed in layers with stainless steel sternal wires and absorbable suture material. Drains were positioned for post-operative monitoring.

Procedure Facts

Figure 2. Intraoperative reconstruction. The ascending aorta has been replaced with a Dacron graft and the bicuspid aortic valve has been replaced with a mechanical bileaflet prosthesis.

The combined procedure achieved its three primary objectives. The infected aortic valve was completely excised and replaced with a competent prosthesis. The dilated ascending aorta was replaced with a vascular graft, removing the risk of dissection. Forward blood flow from the left ventricle to the systemic circulation was restored. Aortic regurgitation was eliminated.

Post-operative recovery was uneventful. The patient was extubated on post-operative day one. He was shifted out of the ICU on post-operative day three. There were no surgical, neurological, or infective complications.

Figure 3. Post-operative result. Reconstructed aortic anatomy with normal calibre, functioning prosthetic valve, and restored sinus rhythm.

Outcomes at a Glance

Discharge Instructions Given to the Patient

• Sternal precautions for six weeks. No lifting of weights heavier than two to three kilograms.
• Lifelong anticoagulation with warfarin for the mechanical aortic valve. INR target range was specified, with weekly monitoring during the first month.
• A six-week course of intravenous antibiotics directed against the organism cultured at admission, transitioned to oral therapy as appropriate.
• Wound care for the sternal incision, with strict instructions to report fever, redness, drainage, or chest wall instability.
• Cardiac rehabilitation referral, beginning with supervised walking and progressing as tolerated.
• Scheduled follow-up at two weeks, six weeks, three months, and six months post-discharge, with echocardiography at the six-week and six-month visits.
• Dental review and prophylactic antibiotic guidance for any future dental work, given the prior endocarditis history.

Recovery Timeline