Prashanth Vallabhajosyula, MD, MS, Caroline Komlo, BS, Wilson Y. Szeto, MD, Tyler J. Wallen, DO, Nimesh Desai, MD, PhD, and Joseph E. Bavaria, MD Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
Background. At our institution, type I bicuspid aortic valve (BAV) patients with aortic insufficiency (AI) who are candidates for valve preservation are stratified into two groups by aortic root pathology: nonaneurysmal root undergoing primary cusp repair D subcommissural annuloplasty (repair group) vs aneurysmal root undergoing primary cusp repair D root reimplantation (reimplantation group). We report outcomes of this surgical reconstructive strategy for the repaired type I BAV. Methods. A retrospective review was performed of 71 patients with a type I BAV undergoing primary valve repair from 2005 to 2012. The repair group (n [ 40) underwent annular stabilization by subcommissural annuloplasty, and the reimplantation group (n [ 31) underwent robust annular stabilization provided by root reimplantation. Results. Preoperative characteristics and root anatomy were similar, except for increased root dimensions in the reimplantation group (p 1þ) and freedom from aortic reoperation at midterm follow-up. As recommended by the American Heart Association guidelines, BAV patients with AI who are candidates for
uccessful repair techniques for bicuspid aortic valve (BAV) patients presenting with aortic insufficiency (AI) have been well described by several groups [1–11]. Because most BAV patients presenting with AI are young, durable primary valve repair is a very attractive and valid treatment option compared with valve replacement, provided long-term outcomes remain equivalent. In this setting, aortic valve reoperation rates range between 15% and 20% at 8 to 10 years of follow-up [1, 2, 6]. Aortic reoperation is typically undertaken for recurrence of AI. Therefore, any techniques that improve the durability of the repaired BAV would significantly enhance the role of primary valve repair for BAV AI. It is well known that primary cusp repair without the use of root stabilization techniques negatively affects
Accepted for publication Oct 25, 2013. Presented at the Poster Session of the Forty-ninth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26–30, 2013. Address correspondence to Dr Bavaria, Thoracic Aortic Surgery Program, University of Pennsylvania Medical Center, 3400 Spruce St, 6 Silverstein, Philadelphia, PA 19104; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2014;97:1227–34) Ó 2014 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.071
ADULT CARDIAC
Root Stabilization of the Repaired Bicuspid Aortic Valve: Subcommissural Annuloplasty Versus Root Reimplantation
1228
VALLABHAJOSYULA ET AL TYPE I BICUSPID AORTIC VALVE REPAIR
ADULT CARDIAC
primary cusp repair at our institution are surgically stratified by aortic root pathology [13]. If the BAV patient does not have aneurysmal aortic root pathology (sinus of Valsalva >4.5 cm), the patient undergoes primary cusp repair with subcommissural annuloplasty for root stabilization. If there is a concomitant aortic root aneurysm (patient has type Ib/II AI), we perform primary cusp repair and valve-sparing root replacement (root reimplantation David V technique). All patients with an ascending aneurysm of the aorta (>4.5 cm) also undergo ascending aorta and transverse hemiarch open distal reconstruction under circulatory arrest. In this study, we compared postoperative and midterm results of type I BAV repair for AI in the context of two different root stabilization techniques used: repair þ subcommissural annuloplasty for valvular pathology vs repair þ root reimplantation for valvular and aneurysmal root pathology.
Patients and Methods This study was approved by the University of Pennsylvania Institutional Review Board.
Patient Population From 2005 to 2012, 166 type I BAV patients were treated for pure AI only (no mixed AI and aortic stenosis): 71 patients underwent primary cusp repair, 40 patients did not have aneurysmal root and therefore underwent cusp repair þ subcommissural annuloplasty (repair group), and 31 patients had concomitant aneurysmal root pathology and therefore underwent cusp repair þ root reimplantation (reimplantation group). Data were prospectively maintained.
Anatomic Features of BAVs Only type 1 BAV patients (raphed conjoint cusp) were included. The majority of patients had a conjoint cusp with a pseudocommissure occurring between the right and left coronary leaflets. Most patients (n ¼ 70) presented with greater than or equal to 21þ AI with a component of type II AI secondary to cusp prolapse seen in 62 patients. All patients in the reimplantation group had type Ib AI, with type II AI seen in 29 patients. In 38 patients (54%), a transverse hemiarch reconstruction was required for a complete repair of the aneurysm of the ascending aorta.
Surgical Technique VALVE EVALUATION AND CUSP REPAIR. The BAV was evaluated in its native state and repair was completed first with the aortic root intact. The repaired valve was reassessed after completion of subcommissural annuloplasty or reimplantation. Techniques of BAV cusp repair have been well described [1]. Raphe release or resection with primary closure was performed in 64 patients (Table 1). Leaflet work included leaflet plication, leaflet decalcification, and fenestration closure, with plication being the most common technique (n ¼ 63). No patch repairs were performed. Six patients required Gore-Tex (W.L.
Ann Thorac Surg 2014;97:1227–34
Gore and Associates, Flagstaff, AZ) stitch free margin shortening for cusp fenestrations that occurred toward the middle of the pathologic leaflet. SUBCOMMISSURAL ANNULOPLASTY. All patients in the repair group underwent annular stabilization with subcommissural annuloplasty. Subcommissural annuloplasty was performed at each commissure by placing a U-shaped Ticron (U.S. Surgical, Norwalk, CT) stitch one-third to onehalf the way down the interleaflet triangle height in a horizontal fashion, from one side of the aortic wall to the other (Fig 1A). ASCENDING AORTA REPLACEMENT. In patients with ascending aorta/sinotubular junction aneurysmal dilatation who met the surgical criteria for resection, ascending aorta with transverse hemiarch reconstruction was also performed. Open distal aortic reconstruction with retrograde cerebral perfusion under deep hypothermic circulatory arrest was performed in all patients undergoing ascending aorta replacement (45% in the repair group and 65% in the reimplantation group). ROOT REIMPLANTATION. The repaired BAV was evaluated for the relation between the conjoint and nonconjoint cusps. If the nonconjoint cusp occupied more than 170 degrees of the annulus at the leaflet insertion site, and this corresponded to the surface area that the cusp occupied at the annular plane, then root reimplantation was performed at 180-180 degree orientation, with each leaflet occupying equal surface area at the annular plane (Fig 1B). If the repaired BAV in its native root was closer to a “typical” type I BAV (the conjoint cusp occupied 7/12 of leaflet insertion site and cusp surface area at the annular plane; nonconjoint cusp occupied 5/12 of the perimeter and annular surface area), then the reimplantation was performed at 150-210 degree orientation [14, 15]. In all cases, the Gelweave Valsalva graft (Vascutek Ltd, Renfrewshire, Scotland) was used for reimplantation (Fig 1A). ECHOCARDIOGRAPHY. Intraoperative transesophageal echocardiography was performed before and after the procedure in all cases. Intraoperative echocardiography guided and confirmed decisions regarding techniques for repair and root stabilization. Echocardiography was performed in all patients to evaluate for residual AI, its orientation, and degree. Coaptation height was assessed, with a goal of at least 5 mm coaptation zone after repair. Any residual AI exceeding 1þ mandated reexploration of the aortic valve. PATIENT FOLLOW-UP. All patients underwent a transthoracic echocardiography at discharge. Patients were followed up in the clinic at 1 month, at least every 6 months thereafter for the first 2 years, and yearly thereafter. If patients did not have new onset of symptoms or changes in examination, echocardiography was performed yearly. Clinical follow-up has remained at 100% and echocardiography follow-up at 97%.
Statistical Analysis Continuous variables are expressed as mean standard deviation. Univariate analysis was performed with the Fisher’s exact test to compare categorical variables and
Ann Thorac Surg 2014;97:1227–34
VALLABHAJOSYULA ET AL TYPE I BICUSPID AORTIC VALVE REPAIR
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Table 1. Patient Demographics, Preoperative Variables, and Intraoperative Outcomes
Age, yrs Male Aortic insufficiency grade 1þ 2þ 3þ 4þ Left ventricular dimensions End-diastolic, mm End-systolic, mm Annulus, mm Sinotubular junction, mm Sinus of Valsalva, mm Ascending aorta, mm Ejection fraction Intraoperative outcomes Cardiopulmonary bypass time, min Aortic cross-clamp time, min Circulatory arrest time, min Leaflet coaptation zone, mm Concomitant operations Hemiarch replacement Intraoperative aortic valve reexploration Coronary artery bypass grafting ASD/VSD closures Aortic leaflet repair All Raphe release Raphe release with primary closure Gore-Texb free margin shortening for cusp perforation Leaflet plication Leaflet decalcification Patch repair Fenestration repair Root stabilization technique Subcommissural annuloplasty Ascending aorta and subcommissural annuloplasty Root reimplantation
Repair Group (n ¼ 40)
Reimplantation Group (n ¼ 31)
46 17 34 (85)
45 11 24 (77)
0 3 8 29
1 12 5 13
(0) (8) (20) (72)
0.74 0.54 –
(3) (38) (16) (42)
61 8 41 9 29 3 33 4 38 5 45 10 0.53 0.08
60 11 36 10 30 4 42 7 50 7 45 13 0.59 0.10
0.64 0.03 0.28
Background. At our institution, type I bicuspid aortic valve (BAV) patients with aortic insufficiency (AI) who are candidates for valve preservation are stratified into two groups by aortic root pathology: nonaneurysmal root undergoing primary cusp repair D subcommissural annuloplasty (repair group) vs aneurysmal root undergoing primary cusp repair D root reimplantation (reimplantation group). We report outcomes of this surgical reconstructive strategy for the repaired type I BAV. Methods. A retrospective review was performed of 71 patients with a type I BAV undergoing primary valve repair from 2005 to 2012. The repair group (n [ 40) underwent annular stabilization by subcommissural annuloplasty, and the reimplantation group (n [ 31) underwent robust annular stabilization provided by root reimplantation. Results. Preoperative characteristics and root anatomy were similar, except for increased root dimensions in the reimplantation group (p 1þ) and freedom from aortic reoperation at midterm follow-up. As recommended by the American Heart Association guidelines, BAV patients with AI who are candidates for
uccessful repair techniques for bicuspid aortic valve (BAV) patients presenting with aortic insufficiency (AI) have been well described by several groups [1–11]. Because most BAV patients presenting with AI are young, durable primary valve repair is a very attractive and valid treatment option compared with valve replacement, provided long-term outcomes remain equivalent. In this setting, aortic valve reoperation rates range between 15% and 20% at 8 to 10 years of follow-up [1, 2, 6]. Aortic reoperation is typically undertaken for recurrence of AI. Therefore, any techniques that improve the durability of the repaired BAV would significantly enhance the role of primary valve repair for BAV AI. It is well known that primary cusp repair without the use of root stabilization techniques negatively affects
Accepted for publication Oct 25, 2013. Presented at the Poster Session of the Forty-ninth Annual Meeting of The Society of Thoracic Surgeons, Los Angeles, CA, Jan 26–30, 2013. Address correspondence to Dr Bavaria, Thoracic Aortic Surgery Program, University of Pennsylvania Medical Center, 3400 Spruce St, 6 Silverstein, Philadelphia, PA 19104; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2014;97:1227–34) Ó 2014 by The Society of Thoracic Surgeons
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.071
ADULT CARDIAC
Root Stabilization of the Repaired Bicuspid Aortic Valve: Subcommissural Annuloplasty Versus Root Reimplantation
1228
VALLABHAJOSYULA ET AL TYPE I BICUSPID AORTIC VALVE REPAIR
ADULT CARDIAC
primary cusp repair at our institution are surgically stratified by aortic root pathology [13]. If the BAV patient does not have aneurysmal aortic root pathology (sinus of Valsalva >4.5 cm), the patient undergoes primary cusp repair with subcommissural annuloplasty for root stabilization. If there is a concomitant aortic root aneurysm (patient has type Ib/II AI), we perform primary cusp repair and valve-sparing root replacement (root reimplantation David V technique). All patients with an ascending aneurysm of the aorta (>4.5 cm) also undergo ascending aorta and transverse hemiarch open distal reconstruction under circulatory arrest. In this study, we compared postoperative and midterm results of type I BAV repair for AI in the context of two different root stabilization techniques used: repair þ subcommissural annuloplasty for valvular pathology vs repair þ root reimplantation for valvular and aneurysmal root pathology.
Patients and Methods This study was approved by the University of Pennsylvania Institutional Review Board.
Patient Population From 2005 to 2012, 166 type I BAV patients were treated for pure AI only (no mixed AI and aortic stenosis): 71 patients underwent primary cusp repair, 40 patients did not have aneurysmal root and therefore underwent cusp repair þ subcommissural annuloplasty (repair group), and 31 patients had concomitant aneurysmal root pathology and therefore underwent cusp repair þ root reimplantation (reimplantation group). Data were prospectively maintained.
Anatomic Features of BAVs Only type 1 BAV patients (raphed conjoint cusp) were included. The majority of patients had a conjoint cusp with a pseudocommissure occurring between the right and left coronary leaflets. Most patients (n ¼ 70) presented with greater than or equal to 21þ AI with a component of type II AI secondary to cusp prolapse seen in 62 patients. All patients in the reimplantation group had type Ib AI, with type II AI seen in 29 patients. In 38 patients (54%), a transverse hemiarch reconstruction was required for a complete repair of the aneurysm of the ascending aorta.
Surgical Technique VALVE EVALUATION AND CUSP REPAIR. The BAV was evaluated in its native state and repair was completed first with the aortic root intact. The repaired valve was reassessed after completion of subcommissural annuloplasty or reimplantation. Techniques of BAV cusp repair have been well described [1]. Raphe release or resection with primary closure was performed in 64 patients (Table 1). Leaflet work included leaflet plication, leaflet decalcification, and fenestration closure, with plication being the most common technique (n ¼ 63). No patch repairs were performed. Six patients required Gore-Tex (W.L.
Ann Thorac Surg 2014;97:1227–34
Gore and Associates, Flagstaff, AZ) stitch free margin shortening for cusp fenestrations that occurred toward the middle of the pathologic leaflet. SUBCOMMISSURAL ANNULOPLASTY. All patients in the repair group underwent annular stabilization with subcommissural annuloplasty. Subcommissural annuloplasty was performed at each commissure by placing a U-shaped Ticron (U.S. Surgical, Norwalk, CT) stitch one-third to onehalf the way down the interleaflet triangle height in a horizontal fashion, from one side of the aortic wall to the other (Fig 1A). ASCENDING AORTA REPLACEMENT. In patients with ascending aorta/sinotubular junction aneurysmal dilatation who met the surgical criteria for resection, ascending aorta with transverse hemiarch reconstruction was also performed. Open distal aortic reconstruction with retrograde cerebral perfusion under deep hypothermic circulatory arrest was performed in all patients undergoing ascending aorta replacement (45% in the repair group and 65% in the reimplantation group). ROOT REIMPLANTATION. The repaired BAV was evaluated for the relation between the conjoint and nonconjoint cusps. If the nonconjoint cusp occupied more than 170 degrees of the annulus at the leaflet insertion site, and this corresponded to the surface area that the cusp occupied at the annular plane, then root reimplantation was performed at 180-180 degree orientation, with each leaflet occupying equal surface area at the annular plane (Fig 1B). If the repaired BAV in its native root was closer to a “typical” type I BAV (the conjoint cusp occupied 7/12 of leaflet insertion site and cusp surface area at the annular plane; nonconjoint cusp occupied 5/12 of the perimeter and annular surface area), then the reimplantation was performed at 150-210 degree orientation [14, 15]. In all cases, the Gelweave Valsalva graft (Vascutek Ltd, Renfrewshire, Scotland) was used for reimplantation (Fig 1A). ECHOCARDIOGRAPHY. Intraoperative transesophageal echocardiography was performed before and after the procedure in all cases. Intraoperative echocardiography guided and confirmed decisions regarding techniques for repair and root stabilization. Echocardiography was performed in all patients to evaluate for residual AI, its orientation, and degree. Coaptation height was assessed, with a goal of at least 5 mm coaptation zone after repair. Any residual AI exceeding 1þ mandated reexploration of the aortic valve. PATIENT FOLLOW-UP. All patients underwent a transthoracic echocardiography at discharge. Patients were followed up in the clinic at 1 month, at least every 6 months thereafter for the first 2 years, and yearly thereafter. If patients did not have new onset of symptoms or changes in examination, echocardiography was performed yearly. Clinical follow-up has remained at 100% and echocardiography follow-up at 97%.
Statistical Analysis Continuous variables are expressed as mean standard deviation. Univariate analysis was performed with the Fisher’s exact test to compare categorical variables and
Ann Thorac Surg 2014;97:1227–34
VALLABHAJOSYULA ET AL TYPE I BICUSPID AORTIC VALVE REPAIR
1229
Table 1. Patient Demographics, Preoperative Variables, and Intraoperative Outcomes
Age, yrs Male Aortic insufficiency grade 1þ 2þ 3þ 4þ Left ventricular dimensions End-diastolic, mm End-systolic, mm Annulus, mm Sinotubular junction, mm Sinus of Valsalva, mm Ascending aorta, mm Ejection fraction Intraoperative outcomes Cardiopulmonary bypass time, min Aortic cross-clamp time, min Circulatory arrest time, min Leaflet coaptation zone, mm Concomitant operations Hemiarch replacement Intraoperative aortic valve reexploration Coronary artery bypass grafting ASD/VSD closures Aortic leaflet repair All Raphe release Raphe release with primary closure Gore-Texb free margin shortening for cusp perforation Leaflet plication Leaflet decalcification Patch repair Fenestration repair Root stabilization technique Subcommissural annuloplasty Ascending aorta and subcommissural annuloplasty Root reimplantation
Repair Group (n ¼ 40)
Reimplantation Group (n ¼ 31)
46 17 34 (85)
45 11 24 (77)
0 3 8 29
1 12 5 13
(0) (8) (20) (72)
0.74 0.54 –
(3) (38) (16) (42)
61 8 41 9 29 3 33 4 38 5 45 10 0.53 0.08
60 11 36 10 30 4 42 7 50 7 45 13 0.59 0.10
0.64 0.03 0.28
