Outcomes of aortic valve repair with the reimplantation technique and maintenance of commissural orientation

Background: Debate still persists on whether valve-sparing root reimplantation (VSRR) of a very asymmetric bicuspid aortic valve (BAV) should be completed such that the asymmetry of the native commissural orientation is retained, or if it should be made symmetric (180°–180°). Herein, we present our approach, in which the native asymmetry is preserved, and the valve is reimplanted in a 210°–150° orientation.
Methods: A retrospective review was performed of 130 patients with BAV who underwent VSRR between January 1, 2004 and March 31, 2023 at a single institution. Of this total, 37 were reimplanted asymmetrically (210°–150°). The primary outcome was > moderate aortic insufficiency (AI). Secondary outcomes included severe aortic stenosis (AS), reintervention, and survival.
Results: The included 37 patients were mostly male [94.6% (35/37)] with mean age of 46.3 years, and with low rates of comorbidities. At least moderate AI was present in 40.5% (15/37) prior to surgery. All BAV in this series were Sievers Type 1 with a mean commissural angle of 128.2°. Leaflet repair was required in 81.1% (30/37), most commonly involving central plication of the conjoined cusp [96.7% (29/30)] and raphe release [73.3% (22/30)]. There was no 30-day mortality or stroke. At 10 years, the cumulative incidences of > moderate AI, severe AS, and reintervention were 7.6% (0–17.2%), 7.1% (0–19.7%), and 5.3% (0.3–22%), respectively. There was no mortality for the entire duration of the study period.
Conclusions: This series demonstrates excellent 10-year outcomes of maintaining commissural orientation in asymmetric BAV reimplantation procedures. However, further study with additional patients, longer follow-up, and direct comparison to symmetric reimplantation for similar BAV morphology is required.