Root Stabilization of the Repaired Bicuspid Aortic Valve: Subcommissural Annuloplasty Versus Root Reimplantation

摘要

Patient PopulationAnatomic Features of BAVsSurgical TechniqueValve evaluation and cusp repairSubcommissural annuloplastyAscending aorta replacementRoot reimplantationEchocardiographyPatient follow-upStatistical AnalysisResultsPreoperative and Intraoperative DataPostoperative OutcomesMidterm Outcomes—Clinical and Echocardiographic Follow-UpAt 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?+ subcommissural annuloplasty (repair group) vs aneurysmal root undergoing primary cusp repair?+ root reimplantation (reimplantation group). We report outcomes of this surgical reconstructive strategy for the repaired type I BAV.MethodsA 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.ResultsPreoperative characteristics and root anatomy were similar, except for increased root dimensions in the reimplantation group (p<0.001). Mortality, stroke, valve reoperation, and pacemaker requirement were zero in both groups. Postoperative peak (19 ± 10 vs 11 ± 5 mm Hg, p < 0.001) and mean gradients (10 ± 5 vs 5 ± 3 mm Hg, p < 0.001) favored root reimplantation. Freedom from AI greater than 1+ was 100% in both groups. Mean follow-up was 40 months in the reimplantation group and 38 months in the repair group. At 5 years, overall survival was 100% in both groups. Freedom from aortic reoperation and AI exceeding 2+ were similar in both groups. Freedom from AI exceeding 1+ was significantly better in the reimplantation group (92% ± 6% vs 62% ± 10%, p?= 0.03). The 2-year peak (14 ± 6 vs 19 ± 9 mm Hg, p?= 0.009) and mean (7 ± 4 vs 11 ± 5 mm Hg, p?= 0.001) gradients favored root reimplantation.ConclusionsRoot stabilization with the reimplantation technique significantly improves the durability of the repaired type I BAV compared with subcommissural annuloplasty. It also provides improved and sustained valve mobility (transvalvular gradients).CTSNet classification:35Successful repair techniques for bicuspid aortic valve (BAV) patients presenting with aortic insufficiency (AI) have been well described by several groups [