We investigated long-term outcomes of bicuspid aortic valve (BAV) repair, with external annuloplasty, according to aorta phenotype.
Between 2003 and 2020, all patients with BAV operated on for aortic insufficiency (AI) and/or aneurysm were included. Repairs included isolated AI repair with subvalvular with or without sinotubular junction (STJ) (single or double) annuloplasty, supracoronary aorta replacement (with or without hemiroot remodeling), and root remodeling with external subvalvular ring annuloplasty.
Among 343 patients operated, reparability rate was 81.3% (n = 279; age 46 ± 13.3 years). At 10 years (median follow-up: 3.42 years; interquartile range, 1.1, 5.8), survival was 93.9% (n = 8 deaths, similar to general population), cumulative incidence of reoperation was 6.2% (n = 10), AI grade >2 was 5.8% (n = 9), and grade >1 was 23.0% (n = 30). BAV repair stabilizing both the annulus and STJ with annuloplasty, compared with nonstabilized STJ repair (single annuloplasty), had lower incidence of reoperation (2.6% vs 22.5%, P = .0018) and AI grade >2 (1.2% vs 23.6%, P < .001) at 9 years. Initial commissural angle <160° was not a risk factor for reoperation, compared with angle ≥160° if symmetrical repair was achieved (2.7% and 4.1%, respectively, at 6 years, P = .85). Multivariable model showed that absence of STJ stabilization (odds ratio, 6.7; 95% confidence interval, 2.1-20, P = .001) increased recurrent AI, but not initial commissural angle <160° (odds ratio, 1.01; 95% confidence interval, 0.39-2.63, P = .98). Commissures adjusted symmetrically led to lower transvalvular gradient, compared with nonsymmetrical repair (8.7 mm Hg vs 10.2 mm Hg, P = .029).
BAV repair, tailored to aorta phenotype, is associated with excellent durable outcomes if both annulus and STJ are reduced and stabilized with external ring annuloplasty. Commissural angle <160° is not associated with reoperation if symmetrical repair is achieved.
Abbreviations and Acronyms:AI (aortic insufficiency), AV (aortic valve), AVIATOR (Aortic Valve International Registry), BAV (bicuspid aortic valve), CI (confidence interval), IQR (interquartile range), OR (odds ratio), STJ (sinotubular junction), SVD (structural valve deterioration), VSRR (valve-sparing root replacement)
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- Bicuspid-associated aortic root aneurysm: mid to long-term outcomes of David V versus the Bio-Bentall procedure.Semin Thorac Cardiovasc Surg. 2021; 33: 933-943
- Contemporary natural history of bicuspid aortic valve disease: a systematic review.Heart. 2017; 103: 1323-1330
- Bentall procedure: a systematic review and meta-analysis.Ann Thorac Surg. 2016; 101: 1684-1689
- Reported outcome after valve-sparing aortic root replacement for aortic root aneurysm: a systematic review and meta-analysis.Ann Thorac Surg. 2015; 100: 1126-1131
- Comparing outcomes between valve-sparing root replacement and the Bentall procedure in proximal aortic aneurysms: systematic review and meta-analysis.Interact Cardiovasc Thorac Surg. 2019; 29: 911-922
- Aortic valve repair versus mechanical valve replacement for root aneurysm: the CAVIAAR Multicentric Study.Eur J Cardiothorac Surg. 2022; 62: ezac283
- 2021 ESC/EACTS guidelines for the management of valvular heart disease.Eur J Cardiothorac Surg. 2021; 60: 727-800
- 2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38: 2739-2791
- State-of-the art bicuspid aortic valve repair in 2020.Prog Cardiovasc Dis. 2020; 63: 457-464
- Isolated bicuspid aortic valve repair with double annuloplasty: how I teach it.Ann Thorac Surg. 2019; 108: 1596-1604
- Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: bicuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 108: 324-333
- Bicuspidization of unicuspid valve using sliding plasty of a rudimentary right-coronary cusp.Eur J Cardiothorac Surg. 2022; 62: ezac360
- A lesional classification to standardize surgical management of aortic insufficiency towards valve repair.Eur J Cardiothorac Surg. 2008; 33 (discussion 878-80): 872-878
- Bicuspid aortic valve repair with hemi-remodeling technique and external ring annuloplasty.J Card Surg. 2020; 35: 146-150
- Isolated aortic insufficiency valve repair with external ring annuloplasty: a standardized approach.Eur J Cardio-Thorac Surg. 2020; 57: 308-316
- Aortic valve fenestration: respect or fix it?.Eur J Cardiothorac Surg. 2022; 62: ezac263
- Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root.J Thorac Cardiovasc Surg. 1998; 115: 1080-1090
- Remodeling or reimplantation for valve-sparing aortic root surgery?.Ann Thorac Surg. 2007; 83: S752-S756
- Reexamining remodeling.J Thorac Cardiovasc Surg. 2015; 149: S30-S36
- Measuring follow-up completeness.Ann Thorac Surg. 2008; 85: 1155-1157
- Standardized definitions of structural deterioration and valve failure in assessing long-term durability of transcatheter and surgical aortic bioprosthetic valves: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) endorsed by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS).Eur Heart J. 2017; 38: 3382-3390
- Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement.N Engl J Med. 2017; 377: 1847-1857
- Risk of thromboembolic events without oral anticoagulation at 90 days after surgical aortic valve replacement with a bioprosthesis.Thromb Haemost. 2018; 118: 945-947
- Propensity-matched comparison of the ross procedure and prosthetic aortic valve replacement in adults.J Am Coll Cardiol. 2022; 79: 805-815
- Aortic annulus diameter affects durability of the repaired bicuspid aortic valve.J Heart Valve Dis. 2015; 24: 412-419
- From dynamic anatomy to aortic annuloplasty: the tale of the ring.in: Aortic Aneurysms: New Insights Into an Old Problem. Liege University Press, 2008: 199-233
- Tirone David valve-sparing aortic root replacement and cusp repair for bicuspid aortic valve disease.J Thorac Cardiovasc Surg. 2013; 145 (e1-2): S35-S40
- Sinus plication to improve valve configuration in bicuspid aortic valve repair-early results.Ann Thorac Surg. 2017; 103: 580-585
- The efficacy of sinus plication in aortic valvuloplasty for bicuspid aortic valve: experiments in a pulsatile flow simulation model.Eur J Cardiothorac Surg. 2021; 60: 859-864
- Valve configuration determines long-term results after repair of the bicuspid aortic valve.Circulation. 2011; 123: 178-185
- Two different geometric orientations for aortic neoroot creation in bicuspid aortic valve repair with root reimplantation.J Thorac Cardiovasc Surg. 2020; 160: 47-57
Published online: November 24, 2022
Accepted: November 11, 2022
Received in revised form: October 26, 2022
Received: July 20, 2022
Publication stageIn Press Journal Pre-Proof
© 2022 by The American Association for Thoracic Surgery
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- Aortic annuloplasty during bicuspid aortic valve repair: “Simple is good but not simpler”(quote Einstein)JTCVS OpenVol. 13
- PreviewIn the past, it was undoubtedly an attractive concept that subvalvular annuloplasty might be sufficient for bicuspid aortic valve (BAV) repair stabilization. However, we now understand that the idea of a functional aortic annulus and its 3-dimensional characteristics requires more sustainability in its repair.
- Commentary: Achieving “symmetrical” annular geometry during bicuspid aortic valve repairThe Journal of Thoracic and Cardiovascular Surgery