Geometric orientation of the aortic neoroot in patients with raphed bicuspid aortic valve disease undergoing primary cusp repair and a root reimplantation procedure
ABSTRACT Primary cusp repair + aortic root reimplantation in bicuspid aortic valve (BAV) disease presenting with root aneurysm with aortic insufficiency (AI) is an effective surgical treatment. We assessed whether the geometric orientation of the repaired BAV into its reimplanted neoroot affects outcomes-180°/180° orientation was compared with the 150°/210° orientation.
From 2005 to 2012, 66 BAV repairs were performed. This is a retrospective review of all types of Ib/II BAV AI patients undergoing root reimplantation (n = 26) at two different geometric orientations: 180°/180° (n = 11) vs 150°/210° (n = 15). In the 180°/180° group, reimplantation into the neoroot was such that both conjoint and non-conjoint cusps occupied 180° of the annular circumference. In the 150°/210° group, the repaired valve was configured to the more typical native orientation of a type I BAV: the non-conjoint cusp occupied 150°, and the conjoint cusp occupied 210° of the annular circumference.
Preoperative characteristics were similar in both groups. In-hospital mortality, stroke, reoperation, renal failure and pacemaker rates were zero in both groups. No patient left the operating room with >1+ AI and one had a peak gradient >20 mmHg. Transvalvular gradients were higher in the 180°/180° group, but not significant (P > 0.05). M.ean follow-ups for the 180°/180° and 150°/210° group were 48 and 33 months, respectively. Actuarial freedom from AI >2+ at 5 years was 100% in both groups. Freedom from AI >1+ at 5 years was 90 ± 10% in the 150°/210° group and 86 ± 13% in the 180°/180° group (P = 0.71). Freedom from peak gradient >20 mmHg was 80% (n = 8) in the 180°/180° group and 100% in the 150°/210° group at 1-year follow-up. Transvalvular gradients were higher in the 180°/180° group (16 ± 8 vs 10 ± 4 mmHg, P = 0.02; 9 ± 3 vs 5 ± 3 mmHg, P = 0.01). Five-year actuarial survival and freedom from aortic reoperation have remained at 100% in the entire cohort.
Cusp repair + root reimplantation for BAV type Ib/II AI can be safely performed at either geometric orientation. Conceptually, 150°/210° orientation respects the natural type I BAV anatomy with regard to cusp surface area and leaflet insertion perimeter. The 180°/180° group may have higher transvalvular gradients and smaller coaptation zones than the 150°/210° group. Further follow-up may reveal the superiority of one geometric orientation over the other.
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ABSTRACT: We sought to compare the safety and durability of bicuspid aortic valve repair versus replacement with a bioprosthesis. We reviewed medical records of patients aged 18 years or older undergoing bicuspid aortic valve repair for aortic regurgitation from 1984 through 2007. We analyzed early outcomes and predictors of aortic valve replacement after initial repair. Patients with repair were compared with an age- and sex-matched cohort who had replacement with a bioprosthesis. Overall survival and survival free from reoperations were compared between groups. The mean follow-up period for 108 consecutive patients with repair was 5.1 (standard deviation, 4.1) years. The initially repaired valve was subsequently replaced in 19 (18%) patients. No bicuspid aortic valve repair technique or morphologic characteristic included in univariate risk factor analysis was associated with increased probability of replacement after initial repair. The 5- and 10-year survival rates after repair were 96% and 87%, respectively. Freedom from valve replacement was 96%, 89%, and 49% at 1, 5, and 10 years after repair, respectively. A separate analysis of 81 matched patients with repair or receipt of an aortic valve bioprosthesis showed no significant difference in 10-year survival (72% vs 79%, P = .13) or freedom from reoperation between groups (90% vs 98% and 72% vs 64% in 5 and 10 years, respectively; P < .12). Bicuspid aortic valve repair is a viable alternative to replacement with a bioprosthesis because durability and safety are similar between both surgical management methods for aortic regurgitation. After initial repair, approximately half of the patients require aortic valve replacement within 10 years.The Journal of thoracic and cardiovascular surgery 04/2010; 139(6):1395-401. DOI:10.1016/j.jtcvs.2010.02.035 · 4.17 Impact Factor
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ABSTRACT: To compare the mid-term results after aortic valve (AV) repair in bicuspid AVs with those in tricuspid AVs. Between 2000 and 2010, 100 patients (mean age 47.2 years) underwent AV repair procedures for insufficient bicuspid AV (n=43) and tricuspid AV (n=57). Aortic regurgitation (AR) more than moderate was present in 31/43 and 21/57 patients in the bicuspid AV and the tricuspid AV group, respectively. Concomitant root replacement by either the reimplantation or the remodeling technique was performed in 42 patients (bicuspid AV 17/43, tricuspid AV 25/57). All patients were prospectively studied with postoperative and further annual clinical assessment and echocardiography. Follow-up was 99% complete with a mean follow-up time of 22 months. Three patients died during the initial hospitalization, all due to postoperative cardiac failure. Overall actuarial 3 years' survival was 93±4.2% without significant differences between the two groups. Overall actuarial 3 years' freedom from AV-related reoperation was 86±5.1% without significant differences between the groups (85±9.7% for bicuspid AV, 86±6.0% for tricuspid AV; log-rank test: p=0.98). Overall actuarial 3 years' freedom from recurrent AR≥moderate was 100% and AR>trace was 71.3±8.2% without significant differences between the groups (76.5±11.7% for bicuspid AV, 71.4±9.4 for tricuspid AV; log-rank test: p=0.97). The mid-term outcome in terms of survival, freedom from reoperation or recurrent AR is similar for both groups of patients after AV repair procedures. Therefore, we advocate valve repair also in patients presenting with an insufficient bicuspid AV.European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2011; 40(5):1097-104. DOI:10.1016/j.ejcts.2011.02.008 · 3.30 Impact Factor
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ABSTRACT: There is increasing interest in the role of valve repair for patients with isolated severe aortic regurgitation. Those with bicuspid aortic valves are suggested as most suitable for repair. Morphologic features of these valves that suggest feasibility of repair are not well defined. Perioperative echocardiograms on 132 consecutive patients (mean age 42 +/- 12 years; 94% male), with bicuspid valves and isolated aortic regurgitation undergoing surgery at our institution were reviewed. Seventy-five patients (57%) underwent successful valve repair. Repair was attempted but unsuccessful for another 8 patients (6 intraoperatively and 2 before discharge). Cusp prolapse was the most common primary mechanism of regurgitation (88 patients [67%]), with 81 patients having primarily eccentrically directed regurgitation. Echocardiographic examination of 72 (55%) had evidence of cusp thickening with 40 (30%) having cusp calcification. By multivariate analysis, an eccentric regurgitant jet direction (odds ratio = 14.3; 95% confidence interval [CI] = 3.4 to 59.6), lack of cusp thickening (odds ratio = 5.9 [1.7 to 20]), lack of cusp calcification (odds ratio = 4.2; [1.1 to 16.7]) and the absence of commissural thickening (odds ratio = 4.8 [1.3 to 16.7]) were independently associated with a greater likelihood of successful valve repair. Greater cusp thickening was the only factor associated with attempted but failed repair. Successful repair of regurgitant bicuspid aortic valves was more feasible for those patients with eccentric regurgitant jets, those without cusp or commissural thickening or cusp calcification. Recognition of these features may enhance patient selection and improve procedural outcomes with aortic valve repair.The Annals of thoracic surgery 06/2005; 79(5):1473-9. DOI:10.1016/j.athoracsur.2004.09.053 · 3.85 Impact Factor