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. 2024 Apr 16:25:1-7.
doi: 10.1016/j.xjtc.2024.03.025. eCollection 2024 Jun.

Effect of graft sizing in valve-sparing aortic root replacement for bicuspid aortic valve: The Goldilocks ratio

Perry S Choi  1 , Amit Sharir  1 , Yoshikazu Ono  1 , Masafumi Shibata  1 , Alexander D Kaiser  2 , Yuanjia Zhu  1 , Alison L Marsden  2 , Y Joseph Woo  1 , Michael R Ma  1 , Joon Bum Kim  1   3
Affiliations

Effect of graft sizing in valve-sparing aortic root replacement for bicuspid aortic valve: The Goldilocks ratio

Perry S Choi et al. JTCVS Tech. .

Abstract

Objective: To investigate the effect of graft sizing on valve performance in valve-sparing aortic root replacement for bicuspid aortic valve.

Methods: In addition to a diseased control model, 3 representative groups-free-edge length to aortic/graft diameter (FELAD) ratio <1.3, 1.5 to 1.64, and >1.7-were replicated in explanted porcine aortic roots (n = 3) using straight grafts sized respective to the native free-edge length. They were run on a validated ex vivo univentricular system under physiological parameters for 20 cycles. All groups were tested within the same aortic root to minimize inter-root differences. Outcomes included transvalvular gradient, regurgitation fraction, and orifice area. Linear mixed effects model and pairwise comparisons were employed to compare outcomes across groups.

Results: The diseased control had mean transvalvular gradient 10.9 ± 6.30 mm Hg, regurgitation fraction 32.5 ± 4.91%, and orifice area 1.52 ± 0.12 cm2. In ex vivo analysis, all repair groups had improved regurgitation compared with control (P < .001). FELAD <1.3 had the greatest amount of regurgitation among the repair groups (P < .001) and 1.5-1.64 the least (P < .001). FELAD <1.3 and >1.7 exhibited greater mean gradient compared with both control and 1.5 to 1.64 (P < .001). Among the repair groups, 1.5 to 1.64 had the largest orifice area, and >1.7 the smallest (P < .001).

Conclusions: For a symmetric bicuspid aortic valve, performance after valve-sparing aortic root replacement shows a bimodal distribution across graft size. As the FELAD ratio departs from 1.5 to 1.64 in either direction, significant increases in transvalvular gradient are observed. FELAD <1.3 may also result in suboptimal improvement of baseline regurgitation.

Keywords: David procedure; aortic root replacement; aortic valve repair; bicuspid aortic valve; free-edge length; graft size; valve-sparing aortic root replacement.

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Conflict of interest statement

The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Figures

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Graphical abstract
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Free-edge length to graft size ratio of 1.5-1.64 results in lowest mean valve gradient.
Figure 1
Figure 1
On the basis of previous simulation work, 3 porcine aortic roots were bicuspidized and tested in validated univentricular simulator for 20 runs for valve-sparing root replacement with varying FELADs: <1.3, 1.5 to 1.64, and >1.7. The control model was based on a typical diseased bicuspid valve with mild-to-moderate regurgitation. All repair conditions were tested in the same root by the same operator to minimize inter-root differences. Graft size significantly affected valve function after repair, with a free-edge length to graft ratio of 1.5 to 1.64 exhibiting ideal performance in ex vivo assessment. FELAD, Free-edge length to aortic/graft diameter.
Figure 2
Figure 2
Valve regurgitation based on free-edge length to graft diameter ratio. ∗∗∗P < .001. All repair groups had significantly improved regurgitation compared with control. Pairwise comparison showed that the <1.3 group had significantly greater regurgitation than both the 1.5 to 1.64 and >1.7 groups. The 1.5 to 1.64 group had significantly lower regurgitation than the >1.7 group. Error bars denote standard error from linear mixed effects model.
Figure 3
Figure 3
Transvalvular gradient based on free-edge length to graft diameter ratio. ∗∗∗P < .001. Linear mixed effects modeling across repair groups showed significantly higher mean transvalvular gradient for the <1.3 and >1.7 groups compared with control, whereas the 1.5 to 1.64 group was not significantly different from control (P = .64). Pairwise comparisons confirmed these results and showed that the 1.5 to 1.64 group had significantly lower mean transvalvular gradient than both the <1.3 and >1.7 groups. Error bars denote standard error from linear mixed effects model.
Figure 4
Figure 4
Valve orifice area based on free-edge length to graft diameter ratio. ∗P < .05, ∗∗∗P < .001. All repair groups had significantly smaller orifice area compared with the control group. Pairwise comparison showed that the 1.5 to 1.64 group had significantly larger orifice area than the <1.3 and >1.7 groups, whereas the >1.7 group had significantly smaller orifice area than the <1.3 group. Error bars denote standard error from linear mixed effects model.
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