Isolated aortic regurgitation in normal-appearing aortic root: what do I do?

Case 1 is a 31-year-old female with a bicuspid aortic valve (BAV) and ascending aortic aneurysm. On computed tomography (CT) angiography, the ascending aorta measured 4.8 cm, which had grown from 4.2 cm one year prior. The aortic root was normal, measuring 3.6 cm. Transthoracic echocardiography (TTE) showed normal left ventricular function and moderate-to-severe aortic insufficiency (AI). This patient was scheduled for elective BAV repair with ascending and hemiarch replacement. Case 2 is a 44-year-old with a BAV. Severe AI and decreased left ventricular function (LVEF 45%) was revealed on TTE, with significant dilatation (LVEDd 7.8 cm). On CT angiography, both the aortic root and ascending aorta were normal, measuring 4.0 cm and 3.8 cm, respectively. This patient was scheduled for elective BAV repair.