Simple bicuspid valve repair

Clinical vignette

A young male presented with severe aortic valve regurgitation from a bicuspid aortic valve. He did not wish to have a mechanical valve, and was not suitable for the Ross procedure. Based on his echo, he had a 75–85% likelihood of having a successful minimally invasive aortic valve repair procedure through a “J” incision, with a 0.25–0.5% risk of death and better than 90% freedom from reoperation based on our data (1).

Surgical technique

A minimally invasive “J” incision from the sternal notch to the right fourth intercostal space was made. Standard cannulization was used and antegrade cardioplegia given, followed by ostial cardioplegia with temperature monitoring.

The valve and root were examined using the CLASS schema [Commissures (raphe), Leaflets, Annulus, Sinotubular junction and Sinuses]. Based on findings for a straightforward bicuspid repair, as shown in the video, the following steps were taken:

• The raphe was resected;
• Cabrol commissure valve sutures were placed to narrow the intercommissural angle;
• The conjoint leaflet plicated at the incomplete fusion with a 5/0 polyester suture;
• Figure-of-eight suspensory polytetrafluoroethylene (PTFE) sutures were placed at the commissure/leaflet junction and suspended at a higher level—about 3–4 mm higher;
• Symmetry and apposition were checked.

For this type of repair, if the root is enlarged, it can be replaced by a beveled graft using a remodeling operation with the coronary ostia reattached via an inclusion technique, as illustrated at the end of the video. The advantage with this method, after the leaflet repair, is that absolute hemostasis can easily be obtained if the buttons or the anastomosis leaks at the annulus.

Comments

While this technique is easy to use, care must be taken to ensure aortic stenosis is not created by a vigorous overcorrection. Indeed, if there is a concern with an annulus smaller than 22–23 mm, a Hegar dilator should be used to check if the orifice may be too small. Also, if there is risk of long-term leaflet prolapse, a leaflet edge running suture is used, and tied down around a Hegar dilator.

In our previous report of 728 bicuspid valve repairs (1), and in another where the aorta was also replaced in 801 cases (2), the risk of death has been <0.5% and the long-term results with repair have been excellent. However, when a reimplantation operation is combined with a bicuspid valve repair, while the results are not statistically different from reimplantation for a trileaflet valve, the long-term results may not be as good for bicuspid valve reimplantation versus trileaflet valve reimplantation (3). Bicuspid valve outcomes are not statistically different now, but probably will be over time. Our overall freedom from reoperation for over 1,100 modified reimplantations is 97% at 10 years, with a 0.17% elective operative mortality risk (4). The advantages of a successful bicuspid valve repair are not needing warfarin (Coumadin), lower risk of stroke and endocarditis, and lower risk of failure of biological valves in younger patients. By contrast, there are poorer outcomes long-term with Ross procedures—particularly associated with regurgitating valves—aneurysmal aortas, and less chance of having a good quality of life than with aortic valve replacement. We also have had no deaths for reoperation of a patient who had an original bicuspid valve repair (1).

Acknowledgments

Funding: None.

Footnote

Conflicts of Interest: The author has no conflicts of interest to declare.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Svensson LG, Al Kindi AH, Vivacqua A, et al. Long-term durability of bicuspid aortic valve repair. Ann Thorac Surg 2014;97:1539-47; discussion 1548. [Crossref] [PubMed]
2. Wojnarski CM, Svensson LG, Roselli EE, et al. Aortic Dissection in Patients With Bicuspid Aortic Valve-Associated Aneurysms. Ann Thorac Surg 2015;100:1666-73; discussion 1673-4. [Crossref] [PubMed]
3. Mokashi SA, Rosinski BF, Desai MY, et al. Aortic root replacement with bicuspid valve reimplantation: Are outcomes and valve durability comparable to those of tricuspid valve reimplantation? J Thorac Cardiovasc Surg 2022;163:51-63.e5. [Crossref] [PubMed]
4. Svensson LG, Rosinski BF, Tucker NJ, et al. Comparison of outcomes of patients undergoing reimplantation versus Bentall root procedure. AORTA 2021; In press.