Valve configuration determines long-term results after repair of the bicuspid aortic valve.

Department of Thoracic and Cardiovascular Surgery, University Hospitals Homburg, Homburg, Germany.
Circulation (Impact Factor: 15.2). 01/2011; 123(2):178-85. DOI: 10.1161/CIRCULATIONAHA.109.934679
Source: PubMed

ABSTRACT Reconstruction of the regurgitant bicuspid aortic valve has been performed for >10 years, but there is limited information on long-term results. We analyzed our results to determine the predictors of suboptimal outcome.
Between November 1995 and December 2008, 316 patients (age, 49±14 years; male, 268) underwent reconstruction of a regurgitant bicuspid aortic valve. Intraoperative assessment included extent of fusion, root dimensions, circumferential orientation of the 2 normal commissures (>160°, ≤160°), and effective height after repair. Cusp pathology was treated by central plication (n=277), triangular resection (n=138), or pericardial patch (n=94). Root dilatation was treated by subcommissural plication (n=100), root remodeling (n=122), or valve reimplantation (n=2). All patients were followed up echocardiographically (cumulative follow-up, 1253 years; mean, 4±3.1 years). Clinical and morphological parameters were analyzed for correlation with 10-year freedom from reoperation with the Cox proportional hazards model. Hospital mortality was 0.63%; survival was 92% at 10 years. Freedom from reoperation at 5 and 10 years was 88% and 81%; freedom from valve replacement, 95% and 84%. By univariable analysis, statistically significant predictors of reoperation were age (hazard ratio [HR]=0.97), aortoventricular diameter (HR=1.24), effective height (HR=0.76), commissural orientation (HR=0.95), use of a pericardial patch (HR=7.63), no root replacement (HR=3.80), subcommissural plication (HR=2.07), and preoperative aortic regurgitation grade 3 or greater. By multivariable analysis, statistically significant predictors for reoperation were age (HR=0.96), aortoventricular diameter (HR=1.30), effective height (HR=0.74), commissural orientation (HR=0.96), and use of a pericardial patch (HR=5.16).
Reconstruction of bicuspid aortic valve can be performed reproducibly with good early results. Recurrence and progression of regurgitation, however, may occur, depending primarily on anatomic features of the valve.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Aortic valvuloplasty could represent an alternative to valve replacement resulting in optimal haemodynamic conditions, avoiding anticoagulation and allowing, in young people, normal aortic annulus growth. We analysed our results of aortic valve repair for incompetence due to leaflets and root pathology. From January 2003 to January 2013, 235 patients affected by aortic valve regurgitation, pure or associated with aortic dilatation, were treated with a combination of the principal leaflet repair techniques and, when necessary, sparing procedures. Of these patients, 218 were considered eligible in this study. All of them were submitted to pre- and postoperative transthoracic echocardiography and pre- and post-repair transoesophageal echocardiography. Follow-up was achieved with periodic echocardiograms and clinical evaluations. Eight patients (3.40%) died before discharge. Median clinical and echocardiographic follow-up for all patients was 2.94 (1.41-5.41) years. Mean cross-clamping time was 101.94 ± 40.22 min and mean hospital stay was 10 ± 6.69 days. Kaplan-Meier freedom from aortic regurgitation >2 and freedom from aortic valve replacement were, respectively, 92.9 ± 2.8 and 94.5 ± 2.5% at 9.24 years: 6 patients (2.75%) were reoperated on with aortic valve replacement for severe aortic regurgitation. We also observed a good effect of aortic surgery on the left ventricle: the end-diastolic volume decreased from 137.89 ± 50.23 ml in the preop to 105.17 ± 31.19 ml at follow-up. Aortic valve leaflet repair seems to be a good and feasible option for selected patients, both alone or associated with an aortic sparing technique concerning long-term results.
    Interactive Cardiovascular and Thoracic Surgery 03/2014; · 1.11 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Aortic annuloplasty and preservation of root dynamics have been described as factors for durability of aortic valve repair. The objective of this study is to document the first clinical analysis of root dynamics after a standardized valve-sparing procedure for root aneurysms associating a calibrated expansible external aortic ring annuloplasty with a physiological remodelling of the aortic root (CAVIAAR technique: Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root). Of the 600 patients operated on with the CAVIAAR technique, 60 consecutive patients from a single team underwent double independent reading of the echocardiographic analysis performed in the operative period and yearly after discharge until a maximum of 5-year follow-up. Forty-four patients had preoperative aortic insufficiency (AI) ≥grade 2 (73.3%) and 29 patients (48%) had bicuspid valves. The expansible aortic ring (median size 27 (25-27) mm) significantly reduced the aortic annular base diameter (from 28 (25-29) mm to 23 (21-24) mm) (P < 0.001) without a significant median transvalvular gradient increase (P = 0.545). Cusp repair was performed in 55 patients (91.7%). Operative mortality was 1.7% (1). During the median 19-month (95% confidential interval [11-26]) follow-up, annular diameter and cusp effective height remained stable. There were no valve-related reoperations. One patient died at 6 months postoperatively from congestive heart failure. Freedom from AI ≥grade 2 was 100% at 1-year follow-up and 96.8% ± 3.2% at 3-year follow-up. Systolic root expansibility of the four echocardiographic diameters (aortic annular base, sinuses of Valsalva level, sino tubular junction and tubular aorta) was maintained, throughout the follow-up period with the aortic annular base expansibility coefficient having consistently higher values than the three other levels. The expansible aortic ring achieved a complete calibrated external annuloplasty and maintained dynamics of the aortic root at mid-term follow-up. Whether this could be a factor for durability of aortic valve repair is currently under evaluation through the CAVIAAR study 10-year follow-up.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 04/2014; · 2.40 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: A 180/180° configuration has been reported to increase repair durability after valve-sparing aortic root replacement (V-SARR) for bicuspid aortic valve (BAV) disease. We studied the impact of commissural angular configuration (CAC) and of BAV type on valve performance after V-SARR.
    Interactive Cardiovascular and Thoracic Surgery 06/2014; · 1.11 Impact Factor