Early results of geometric ring annuloplasty for bicuspid aortic valve repair during aortic aneurysm surgery

Abstract

Objectives: Geometric ring annuloplasty has shown promise during bicuspid aortic valve repair for aortic insufficiency. This study examined early outcomes of bicuspid aortic valve repair associated with proximal aortic aneurysm replacement.

Methods: From September 2017 to November, 2021, 127 patients underwent bicuspid aortic valve repair with concomitant proximal aneurysm reconstruction. Patient age was 50.6 ± 12.7 years (mean ± standard deviation), male gender was 83%, New York Heart Association Class was 2 (1-2) (median [interquartile range]), and preoperative aortic insufficiency grade was 3 (2-4). Ascending aortic diameter was 50 (46-54) mm, and all patients had ascending aortic replacement. Forty patients had sinus diameters greater than 45 mm, prompting remodeling root procedures. A total of 105 patients had Sievers type 1 valves, 3 patients had type 0, and 7 patients had type 2. A total of 118 patients had primarily right/left fusion, 8 patients had right/nonfusion, and 1 patient had left/nonfusion. Leaflet reconstruction used central leaflet plication and cleft closure, with limited ultrasonic decalcification in 31 patients.

Results: Ring size was 23 (21-23) mm, and 26 of 40 root procedures were selective nonfused sinus replacements. Aortic clamp time was 139 (112-170) minutes, and bypass time was 178 (138-217) minutes. Postrepair aortic insufficiency grade was 0 (0-0) (P < .0001), and mean valve gradient was 10 (7-14) mm Hg. No early and 1 late mortality occurred. Four patients required reoperation for bleeding, and 4 patients required pacemakers. At a mean follow-up of 20 months (maximal 93), there were no valve-related complications, 5 late repair failures prompting valve replacement, and 1 death due to Coronavirus Disease 2019.

Conclusions: Geometric ring annuloplasty for bicuspid aortic valve repair with proximal aortic aneurysm reconstruction is safe and associated with good early outcomes. Further experience and follow-up will help inform long-term durability.

Keywords: AI, aortic insufficiency; BAV, bicuspid aortic valve; aortic aneurysm repair; aortic insufficiency; bicuspid valve repair.

Graphical abstract

BAV repair with hemi-root replacement. Bicuspid repair using geometric ring annuloplasty and root remodeling with single sinus resection followed by aneurysm repair.

Figure 1

A, BAV annuloplasty ring. B, Leaflet ball sizer used in this series.

Figure 2

A, Typical type 1 BAV is shown with the right-left commissure comprising a complete fusion (fused leaflet raphe) and a thickened fused cusp cleft. B, The leaflet reconstruction is begun by plicating the nonfused cusp to an 8- to 10-mm effective height. C, Spacing sutures are placed from the center of the nonfused cusp across to the fused cusp, equidistant from the commissure, on both sides of the cleft. This sets up the cleft for closure, producing a 2-leaflet valve with similar effective height, geometric height, and free-edge length. Illustration adopted from Schäfers with permission. eH, Effective height; gH, geometric height; FEL, free-edge length.

Figure 3

After BAV repair, the ring annular sutures are evident, as well as the linear cleft closure and nonfused leaflet plication. An asymmetrically enlarged noncoronary sinus is being excised in preparation for an ascending aortic and hemi-root replacement. Leaflet coaptation is good with similar effective height, geometric height, and free-edge length.

Figure 4

A, BAV repair failure due to suturing ring into the base of the nonfused cusp with subsequent leaflet abrasion from ring Dacron. This was a nonaneurysmal BAV repair, reported previously. B, Video frame from the third repair failure, showing a fractured polypropylene suture, release of the ring toward the valve center, and abrasion of the leaflet.

Figure 5

Comparison of pathologic annular diameter (measured with a Hegar dilator before repair) to the “ideal” annular diameter predicted from leaflet free-edge length/1.5 in the 88 patients with prerepair Hegar annular diameter measurements. The line of identity is the heavy thick line, and the linear regression is the thinner line. The regression equation was Y = 0.7886 × X + 9.627 (P < .0001). Mean ± standard deviation for pathologic diameter was 27.3 ± 3.7 mm and for “ideal” diameter was 22.7 ± 1.9 mm (P < .0001). BAV, Bicuspid aortic valve.

Figure 6

Kaplan–Meier analysis of time-varying events after BAV and proximal aneurysm repair in 127 patients. The composite outcome of interest was survival free of reoperation or valve-related complications. Patients from the early device clinical trials are on the upper right. Blue shading indicates ± 95% confidence limits. Lighter blue shading denotes data from the last 10% of the population. CI, Confidence interval.

Figure 7

Graphical summary of the study showing the geometry of the BAV annuloplasty ring on the left, an operative photograph of the leaflet repair technique in the center, and the outcomes observed on the right. BAV, Bicuspid aortic valve; CI, confidence interval; AI, aortic insufficiency; AVR, aortic valve replacement.