To the Editor:

We have reviewed the article entitled “Longer-term outcomes after bicuspid aortic valve repair in 142 patients” by mojyan safari MD et al.¹ with great enthusiasm. We were fortunate to review this valuable article which was informative and productive. We acknowledge the prime conclusion of the study that bicuspid aortic valve repair is associated with fewer postoperative clinical complications and the long-lasting durability of the valve. However, few concerns arise, which masks the findings of the study.

Firstly, conducting a study with having a small number of participants could alter the authenticity of the study. The authors should have reflected on taking a large sample size as fewer participants may modify the study’s findings. For example, a 2011 study decided to include 316 patients to achieve the study’s authenticity.²Secondly, sex differences have also been found to have an impact on the findings of the study. The author’s in their study have included only the male sex hence neglecting the female sex. Whereas a 2015 study highlighted that females tend to have more extended postoperative hospital stays and receive a maximum number of postoperative blood products.³

Moreover, as established, smoking is highly associated with increased chances of contributing to vascular atherosclerotic plaque and calcification on the aortic valve, which can be a potential reason for complicated longer outcomes in bicuspid aortic valve repair patients. Therefore, the authors should have widened their inclusion criteria and included smoking as one of the participant variables since ignoring patient characteristics may affect the study’s outcome.⁴ Lastly, this single-centered study comes up with numerous concerns regarding its findings. To overcome this issue, the authors should have included participants from multiple centers and locations because of the impact of different races and socioeconomic populations on the study. For illustration, a 2011 study included participants from the whole of Olmsted country diagnosed with bicuspid aortic valve and appear authentic.⁵

Finally, more studies must be conducted on patients with bicuspid aortic valves to improve the prognosis and potentially reduce longer-term complications.