Bicuspid aortic valve repair adapted to aortic phenotype

Abstract

The bicuspid aortic valve (BAV) is the most common congenital cardiovascular anomaly and may present with differing phenotypes including almost constant annular dilation. We have developed a standardized approach to BAV repair with a systematic adjunct of aortic annuloplasty according to the three phenotypes of the proximal aorta, which include a dilated aortic root, dilated ascending aorta and normal root and ascending aorta. In our cohort of 191 patients, freedom from AV-related re-intervention was 98% for remodeling with annuloplasty (n=100) and 100% for tubular aortic replacement with annuloplasty (n=31) at 8 years. In an isolated aortic insufficiency (AI) group, freedom from AV-related re-intervention varied from 72.4% with a single subvalvular annuloplasty ring (n=31) compared to 100% at 6 years when a double sub- and supra-valvular (STJ) annuloplasty ring was performed (n=29). Restoration of the annulus: sinotubular junction (STJ) ratio is a key factor to ensure longevity of the bicuspid valve repair and freedom from re-intervention.

Keywords: Bicuspid aortic valve (BAV); aortic repair; ring annuloplasty.

Figure 1

Six sub-valvular pledgeted polyester ‘U’ stitches pledgeted polyester needle are placed inside out circumferentially in the subvalvular plane. One stitch is placed 2 mm below the nadir of each cusp and one below each commissure at the base of the inter-leaflet triangles except at the level of the right-noncoronary commissure where it is placed externally in order to avoid lesions of the bundle of His and membranous septum.

Figure 2

First step of cusp repair: alignment of cusp free edges. A stay suture of 6-0 polypropylene is passed through each nodule of Arantius. A grasper pulls outwards on the corresponding commissure while the two stitches at the level of the nodules are retracted on the opposite side. Excess length of the free edge is then determined. The same step is performed for the other hemi-cusp. The distance between the two stitches determines the area for the central plicating stitches or limited resection of a median raphe to equalize each hemi-cusp when the length exceeds 5 mm.

Figure 3

Remodeling of the aortic root is standardized by scalloping the tube graft into two symmetrical neo-sinuses with commissures at 180°. The heights of the scallops to suture the commissures are cut up to the transition point between circumferential and axial folds in the graft. Remodeling suturing (4-0 or 5-0 polypropylene) starts at the nadir of the sinus towards the hemi-sinus. In order to avoid commissural distortion, another running suture is commenced at the tip of the commissure towards the corresponding hemi-sinus.

Figure 4

Second step of cusp repair: commissural traction sutures are placed in order to measure the effective height of each cusp. The cusp caliper is used to evaluate any residual or induced cusp prolapse on the unfused cusp. Plicating stitches are added on the free edge of the culprit leaflet only if the effective height is significantly lower than 9 mm in order to preserve the length of the non-fused cusp to maintain long term opening of the valve. Realignment of the free edges of the cusps is then performed with plicating stitches.

Figure 5

The six anchoring ‘U’ stitches are then passed around the prosthetic aortic ring. The ring is brought down externally around the remodeled aortic root.

Video 1

Remodelling root repair with expansible aortic ring annuloplasty.

Figure 6

Six sub-valvular pledgeted polyester ‘U’ stitches are placed inside out circumferentially in the subvalvular plane. One stitch is placed 2mm below the nadir of each cusp and one below each commissure at the base of inter-leaflet triangles except at the level of the right-noncoronary commissure where it is placed externally in order to avoid lesions of the bundle of His and membranous septum.

Figure 7

After resection of the non-coronary sinus, the first step of cusp repair: alignment of cusp free edges. A 6-0 polypropylene stay suture is passed through each noduli of Arantius. a grasper pulls outwards on the corresponding commissure while the two stitches at the level of the noduli of Arantia are tracted on the opposite side. Excess of length of free edge is then determined. This same step is performed for the other hemi cusp. Distance between the two stitches determines the area for the central plicating stitches or limited resection of a median raphe to equalize each hemi-cusp when excess length is >5 mm (polypropylene 5 or 6-0).

Figure 8

In case of asymmetric commissural orientation <170°, a plication of the sinus at raphe level is added in order to improve the symmetrical design of the repair. Plication is performed from the external side with a couple of “U” stitches of 2-0 coated polyester fibre pledgeted sutures from either side of the raphe. The first stich is placed above the valve and the second above the first (toward the STJ).

Figure 9

Standardized scalloping of the tube graft into one neo-sinus with commissures at 180°. The heights of the scallops to suture the commissures to were cut up to the transition point between circumferential and axial folds in the graft. Suturing of the scallop is started at the nadir of the sinus towards half sinus. In order to avoid commissural distortion, another running suture is begun at the tip of the commissure towards the corresponding hemi-sinus (polypropylene 4.0 or 5.0).

Figure 10

Commissural traction sutures are placed in order to measure the effective height of each cusp. The cusp caliper is used to evaluate any residual or induced cusp prolapse on the un-fused cusp. Plicating central stitches are added on the free edge of this cusp until an effective height of 9 mm is obtained. Realignment of the free edges of the fused and unfused cusps is performed by plicating stitches.

Figure 11

Open external ring annuloplasty passed under the coronary arteries.

Figure 12

The six anchoring ‘U’ stitches are passed around the open aortic ring. The ring is closed at the level of the noncoronary sinus.

Video 2

Hemi-remodeling root repair with expansible aortic ring annuloplasty.

Figure 13

Six sub-valvular pledgeted polyester ‘U’ stitches are placed inside-out circumferentially in the subvalvular plane. One stitch is placed 2 mm below the nadir of each cusp and one below each commissure at the base of the inter-leaflet triangles, except at the level of the right-noncoronary commissure, where it is placed externally in order to avoid lesions of the bundle of His and membranous septum.

Figure 14

Alignment of cusp free edges is performed. A 6-0 polypropylene stay suture is passed through each nodule of Arantius. A grasper pulls outwards on the corresponding commissure while the two stitches at the level of the nodule retracted on the opposite side. Excess length of free edge is then determined. The same step is performed for the other hemi-cusp. Distance between the two stitches determines the area for the central plicating stitches or limited resection of a median raphe to equalize each hemi-cusp if the length exceeds 5 mm.

Figure 15

In cases of asymmetric commissural orientation <170°, plication of the sinus at the level of the raphe is added in order to improve the symmetrical design of the repair. Plication is performed from the external side with a couple of 2-0 coated polyester pledgeted ‘U sutures from either side of the raphe. The first stich is placed above the valve and the second above (towards the STJ).

Figure 16

2-0 pledgeted polyester STJ sutures are placed circumferentially inside out. One stitch is placed a couple mm above each commissure and One stitch above each coronary ostia. Commissures are placed symmetrically at 180 for the two functional commissures on the STJ ring using the expandable external aortic ring.

Figure 17

Commissural traction sutures are placed in order to measure the effective height of each cusp. The cusp caliper is used to evaluate any residual or induced cusp prolapse on the un-fused cusp. Plicating central stitches are added on the free edge of this cusp until an effective height of 9 mm is obtained. Realignment of the free edges of the fused and unfused cusps is performed by plicating stitches.

Figure 18

The six anchoring ‘U’ stitches are then passed around the open aortic ring. The ring is closed at the level of the non-coronary sinus.

Video 3

Isolated bicuspid aortic valve repair: Double sub and supra-valvular external ring annuloplasty.