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Commentary: Truncal root remodeling: A useful technique that can be translated to other lesions?

Published:February 01, 2020DOI:https://doi.org/10.1016/j.jtcvs.2020.01.041
      Can truncal root remodeling be translated to other lesions?
      See Article page 368.
      Naimo and colleagues
      • Naimo P.S.
      • Fricke T.A.
      • Lee M.G.Y.
      • d’Udekem Y.
      • Brink J.
      • Brizard C.P.
      • et al.
      The quadricuspid truncal valve: surgical management and outcomes.
      present their review of patients with truncal root dysfunction who underwent truncal root remodeling. The main finding of the study is that tricuspidization-type reconstruction in quadricuspid dysfunctional valves yielded the best result over the long term. Dysfunctional aortic roots are something we are faced with more and more in the setting of congenital heart surgery; for example, dysfunctional truncal roots truncus arteriosus, dilated neoaortic root in arterial switch operations, and dilated aortic roots in conotruncal abnormalities. The authors present data regarding remodeling dysfunctional quadricuspid roots into tricuspid roots—this represents a technique that has been well described in literature to provide a durability advantage.
      • Myers P.O.
      • Bautista-Hernandez V.
      • del Nido P.J.
      • Marx G.R.
      • Mayer J.E.
      • Pigula F.A.
      • et al.
      Surgical repair of truncal valve regurgitation.
      Another technique that has been described includes bicuspidization of these roots to make them more competent. Other centers have reported durable, long-term freedom from repeat valve repair and replacement with this primary repair strategy.
      • Kaza A.K.
      • Burch P.T.
      • Pinto N.
      • Minich L.L.
      • Tani L.Y.
      • Hawkins J.A.
      • et al.
      Durability of truncal valve repair.
      This type of autologous root remodeling is a valuable tool in our surgical repertoire. There are multitude of cardiac defects with dilated roots and resultant valvular dysfunction and this type of cusp resection and remodeling could be a valuable tool in making these roots less dysfunctional. In my opinion, this type of autologous remodeling and reconstruction would provide the most durable repair for growing children and thus should remain the procedure of choice. There are several technical caveats that need to be kept in mind with regard to cusp excision and remodeling, the key points being the mobilization of coronary arteries that can be unusually oriented in truncal roots and the reinforcement of the new commissure that is created after cusp resection because this area is usually under some tension and would benefit from reinforcement.
      The focus of the article by Naimo and colleagues
      • Naimo P.S.
      • Fricke T.A.
      • Lee M.G.Y.
      • d’Udekem Y.
      • Brink J.
      • Brizard C.P.
      • et al.
      The quadricuspid truncal valve: surgical management and outcomes.
      is remodeling related to reducing the number of cusps and thus gaining a functional advantage. The group has shown good results with using this technique, and highlights the advantage of having a competent aortic valve from the neonatal period onward. Among the important take-home messages is the decision to tackle the truncal valve at the time of primary repair if the level of insufficiency is moderate or greater. There is some operator variability with regard to grading truncal valve insufficiency with echocardiography, and it may be something that is better resolved with additional imaging if there are significant questions about the grade of insufficiency. This are the type of objective data that could help surgeons decide on the best treatment for these complex neonates. The Melbourne group has a track record of publishing long-term follow-up on patients with complex defects. Along these lines, their latest article provides good follow-up data and analysis of intervention-free survival. Although the early mortality in truncal valve repair patients was high (14%), the 15-year survival was very high: 77%. The more important data are the freedom from truncal valve operations: 30% at 15 years. This points to the fact that these valves are intrinsically dysfunctional and may need to be eventually re-repaired or replaced. The authors further show that the tricuspidization technique provides a reintervention-free period of 64% at 10 years. In other words, if the valve morphology is such that a quadricuspid truncal valve is insufficient, the best repair technique may be remodeling with cusp resection. Once again, good quality echocardiography can help guide surgeons identify the ideal technique for making valves more competent.

      References

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        • Fricke T.A.
        • Lee M.G.Y.
        • d’Udekem Y.
        • Brink J.
        • Brizard C.P.
        • et al.
        The quadricuspid truncal valve: surgical management and outcomes.
        J Thorac Cardiovasc Surg. 2021; 161: 368-375
        • Myers P.O.
        • Bautista-Hernandez V.
        • del Nido P.J.
        • Marx G.R.
        • Mayer J.E.
        • Pigula F.A.
        • et al.
        Surgical repair of truncal valve regurgitation.
        Eur J Cardiothorac Surg. 2013; 44: 813-820
        • Kaza A.K.
        • Burch P.T.
        • Pinto N.
        • Minich L.L.
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        Durability of truncal valve repair.
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