Bicuspid aortic valve repair using geometric ring annuloplasty: A first-in-humans pilot trial.

OBJECTIVE: As bicuspid aortic valve (BAV) repair evolves, more effective annular reduction and stabilization could be advantageous. A geometric annuloplasty ring has been developed, and 2-year regulatory outcomes of a first-in-humans pilot trial are reported. METHODS: A prospective first-in-humans trial of BAV ring annuloplasty was completed in 16 patients. Patient age was 44.4 ± 11.3 (mean ± standard deviation) years, preoperative aortic insufficiency grade was 2.5 ± 1.0, New York Heart Association class 1.8 ± 0.4, and mean systolic gradient 13.4 ± 12.9 mm Hg. Three patients had Sievers type 0 BAV, 11 had type 1, and 2 were type 2. The Dacron-covered titanium rings had circular base geometry with 180° subcommissural posts and were implanted subannularly. Leaflets were reconstructed using plication/cleft closure, creating an effective height of ≥8 mm, even if modest gradients were induced. RESULTS: Mean pre-repair annular diameter was 28.6 ± 3.3 mm, and the average ring diameter was 22.3 ± 1.6 mm. All valves required leaflet plication/reconstruction; pericardium was avoided; and 7 patients had aortic replacement for aneurysms. No early mortalities or major complications occurred. Two patients required early prosthetic valve replacement for technical errors, and all were between 24-38 months' postoperative at follow-up. No late mortalities or valve-related complications occurred, and all patients reverted to New York Heart Association class I. Aortic insufficiency reduction was significant to grade 0.9 ± 0.5 at 2-years (P < .0001). Mean valve gradients were acceptable (13.3 ± 5.0 mm Hg at 2 years; overall P = .11) and tended to fall over time (P < .0001). CONCLUSIONS: Geometric ring annuloplasty was safe and effective for BAV repair. AI reduction was significant, valve gradients were satisfactory, and clinical outcomes were excellent. Geometric ring annuloplasty could simplify and standardize BAV repair.

Sinus Plication to Improve Valve Configuration in Bicuspid Aortic Valve Repair-Early Results.

BACKGROUND: Previous experience with repair of the regurgitant bicuspid aortic valve (BAV) has shown a strong influence of commissural orientation on repair durability. We have modified commissural orientation by asymmetric plication of the fused sinuses. We analyzed the results of the modified technique. METHODS: Between 2009 and 2014, 35 patients with BAV and commissural orientation of no more than 160° underwent aortic valve repair, including plication of the fused sinuses and circular annuloplasty. The control group consisted of 21 historic controls undergoing operations between 2000 and 2008 but without sinus plication; subcommissural plication was used as annuloplasty. The groups were similar in most respects; differences existed in preoperative annular diameter, prevalence of complete fusion, use of a pericardial patch, and plication of the fused cusp. RESULTS: At discharge the degree of aortic regurgitation (AR) was significantly lower in the study group (p = 0.004). Survival after 5 years was 100% in the study group and 95.2% in the control group after 5 and 10 years. Five-year freedom from reoperation in the study group was 93.0% and 57.1% in the control group (p = 0.0013); freedom from valve replacement was 95.8% and 79.3% (p = 0.036). Freedom from recurrent AR grade II or higher was 67.1% in the study group and 33.3% in the control group (p = 0.0024). Mean postoperative peak gradient was significantly lower in the study group (14.3 ± 6.5 mm Hg versus 28.9 ± 18.5 mm Hg, p = 0.003). CONCLUSIONS: Plicating the fused sinuses and thus reducing root circumference in the fused part changes commissural orientation of the BAV which leads to better short- and midterm stability in BAV repair.

Suture Annuloplasty Significantly Improves the Durability of Bicuspid Aortic Valve Repair.

BACKGROUND: Isolated repair of the regurgitant bicuspid aortic valve (BAV) has yielded suboptimal durability, with annular dilatation being important risk factor for recurrent aortic regurgitation. We hypothesized that adding a suture annuloplasty (SA) should lead to improved repair stability. METHODS: Between July 1999 and September 2014, 268 patients (mean age, 41 ± 13 years, 249 male) underwent isolated BAV repair. From January 2009 to September 2014, 164 consecutive patients (study group) underwent SA using either braided polyester (n = 37) or expanded polytetrafluorethylene (PTFE) (n = 127). Patients who underwent surgery prior to January 2009 served as controls (n = 104). All patients were followed (98.9% complete, 1 week to 181 months). RESULTS: Annular size was larger in the study group (p < 0.001) and age was lower (p < 0.001). There were no differences between the groups regarding other clinical data. Hospital mortality was 0.7% (n = 2), 10-year survival was 94.2%. Thirty-six patients required valve-related reoperations (8 days to 94 months postoperatively; controls = 32, study = 4). Complications related to SA (ventricular septal defect, interference with coronary artery) occurred in 6 (3.7%) patients, in 4 (10.8%) patients with polyester SA and in 2 (1.6%) patients with PTFE. In the control group freedom from reoperation at 5 and 10 years was 73.2% and 63.7%, respectively. With SA, 5-year stability was significantly improved to 92.6% (p = 0.0006); it was 96.7% for PTFE versus 83.5% for polyester SA (p = 0.0132). CONCLUSIONS: Annular dilatation is a risk factor for failure after repair of regurgitant BAV. Its elimination through the use of SA significantly improves repair stability. With PTFE as material for SA optimal repair stability and minimal local complications are achieved.

Aortic root remodeling leads to good valve stability in acute aortic dissection and preexistent root dilatation.

OBJECTIVES: To evaluate the long-term results of aortic root remodeling in the setting of acute aortic dissection type A (AADA). METHODS: Between October 1995 and May 2013, a total of 215 patients were treated surgically for AADA. Of these, 59 patients with AADA (<2 weeks from onset, age 56 ± 16 years, 53 males) with a root diameter of ≥43 to 45 mm (depending on patient size) underwent aortic root remodeling and were analyzed further. Reimplantation was performed in 7 patients; root replacement with a mechanical composite graft, in 16 patients; root replacement with a stentless biological prosthesis, in 10 patients; and tubular ascending aortic replacement, in 133 patients. RESULTS: Reexploration for bleeding was performed in 10 patients (17%; 8% since 2007). Early mortality was 6.8%; no patient died after 2002. Actuarial survival at 10 years was 72% ± 6%. One patient underwent aortic valve replacement for recurrent cusp prolapse at 1 year after surgery. In this operation, cusp configuration was assessed by eyeballing until 2003. The rate of freedom from proximal reoperation at 10 years was 98% ± 2%. Using a Cox proportional hazards model, no independent predictors for survival and reoperation after remodeling were found. Advanced age and concomitant coronary artery bypass grafting were identified as independent predictors for survival in all 215 patients with AADA. CONCLUSIONS: Root remodeling allows for stable valve preservation in patients with AADA and preexistent root dilatation.

Suture Annuloplasty in Aortic Valve Repair.

There is increasing evidence that an annuloplasty is needed in aortic valve repair. We describe the technique of a suture annuloplasty that we have used successfully in 400 patients treated by aortic valve repair.

European multicenter experience with valve-sparing reoperations after the Ross procedure.

BACKGROUND: Autograft valve preservation at reoperation may conserve some of the advantages of the Ross procedure. However, results of long-term follow-up are lacking. In this retrospective multicenter study, we present our experience with valve-sparing reoperations after the Ross procedure, with a focus on long-term outcome. METHODS: A total of 86 patients from 6 European centers, who underwent valve-sparing reoperation after the Ross procedure between 1997 and 2013, were included in the study. RESULTS: Reoperation was performed a median of 9.1 years after the Ross procedure in patients with a median age of 38.4 years (interquartile range: 27.1-51.6 years). Preoperative severe autograft regurgitation (grade ≥3) was present in 46% of patients. In-hospital mortality was 1%. During a median follow-up of 4.3 years, 3 more patients died of noncardiac causes, resulting in a cumulative survival at 8 years of 89% (95% confidence interval: 65%-97%). Fifteen patients required a reintervention after valve-sparing reoperation, mostly owing to prolapse or retraction of autograft cusps. Freedom from reintervention was 76% (95% confidence interval: 57%-87%) at 8 years. The reintervention hazard was increased in patients who had isolated and/or severe aortic regurgitation at valve-sparing reoperation. In patients without reintervention after valve-sparing autograft reoperation (n = 63), severe aortic regurgitation was present in 3% at last follow-up. CONCLUSIONS: Valve-sparing autograft reoperations after the Ross procedure carry a low operative risk, with acceptable reintervention rates in the first postoperative decade. Patients with isolated and/or severe autograft regurgitation have an increased hazard of reintervention after valve-sparing reoperation; for these patients, careful preoperative weighing of surgical options is required.

Reexamining remodeling.

OBJECTIVE: Root remodeling was proposed as valve-preserving root replacement to treat patients with aortic regurgitation and root aneurysm. The objective of this retrospective study was to review 18 years of experience with root remodeling and to identify predictors of valve durability. METHODS: Between October 1995 and December 2013, root remodeling was performed in 747 patients. The aortic valve anatomy was tricuspid in 431 patients, bicuspid in 290 patients, and unicuspid in 26 patients. Aortic aneurysm was present in 688 patients, and 59 procedures were performed for acute aortic dissection type A. The severity of aortic regurgitation ranged from grade 0 to IV (grade 0, 1%; grade 1, 8%; grade 2, 26%; grade 3, 62%; grade 4, 3%; median, 3). All patients underwent root remodeling, concomitant operations were performed in 352 patients, and cusp repair was used in 690 procedures. RESULTS: Hospital mortality was 2%. Overall freedom from reoperation was 92% at 10 years and 91% at 15 years. Overall freedom from reoperation was 95% for tricuspid valves at 10 and 15 years, 89% for bicuspid aortic valves at 10 years (P = .006), and 83% for bicuspid aortic valves at 15 years. By multivariate analysis, the strongest risk factors for failure were an aortoventricular junction 28 mm or greater (hazard ratio, 1.43) and the use of a pericardial patch as part of cusp repair (hazard ratio, 6.24). CONCLUSIONS: Root remodeling continues to be a viable option in valve-preserving root replacement. If combined with careful assessment and, if necessary, correction of aortic valve geometry, reproducible restoration of aortic valve function can be achieved with good long term durability.

Válvula aórtica bicúspide: resultados a largo plazo de la cirugía reparadora / Long-term Results with Reconstructiva Surgery of the Bicuspid Aortic Valve

Introducción: La válvula aórtica bicúspide es la anomalía congénita cardíaca más frecuente. En pacientes con requerimienro de cirugía, el tratamiento tradicional ha sido la sustitución valvular. La introducción del concepto de reparación de la válvula aórtica bicúspide ha llevado a nuestro grupo a reproducir las técnicas de reparación, las cuales se han estandarizado y aplicado de manera homogénea en nuestras instituciones. Objetivos: Revisar la experiencia conjunta de tres centros, con la presentación de los resultados a mediano y a largo plazos de la reparación valvular. Material y métodos: Entre octubre de 1995 y febrero de 2013 se intervinieron 666 pacientes con válvulas bicúspides e insuficiencia aórtica y/o aneurisma de la aorta. De ellos, 254 presentaban insuficiencia aórtica aislada y 412, aneurisma o disección. Se reconstruyó la válvula en todos los pacientes (en 254 como procedimiento aislado, en 281 "remodelación de la raíz", en 129 remodelación de la unión sinotubular y en 2 "reimplantación"). Resultados: La mortalidad fue de 3/666 (0,5%): 1/254 (0,4%) tras reparación valvular aislada y 2/410 (0,5%) tras reparación más reemplazo de la aorta. En pacientes con cirugía asociada (coronaria, reparación mitral/tricúspide) fue de 1/77 (1,3%). Durante el seguimiento murieron 12 pacientes (supervivencia a los 10 años: 95%). Las libertades de reoperación y de sustitución valvular a los 10 y 15 años fueron del 80% y 77% y del 86% y 83%, respectivamente. La libertad de reoperación a los 10 años fue superior en el reemplazo de la raíz (86%) o la aorta tubular (84%) en comparación con la reparación aislada (74%; p = 0,005). La libertad de cualquier complicación relacionada con la válvula fue del 80% y 77% a los 10 y 15 años, respectivamente, y fue mejor para reparación incluyendo "remodelación de la raíz" (87% y 82%) que para reparación aislada (77% y 77%; p = 0,04). Conclusiones: La reparación de la válvula aórtica bicúspide es un procedimiento seguro y duradero, con una incidencia baja de "complicaciones relacionadas con la válvula" a mediano y a largo plazos.

Introduction: Bicuspid aortic valve is the most common congenital heart disease. Traditionally, aortic valve replacement has been the approach for patients requiring surgery. After introduction of the bicuspid aortic valve repair concept, our group began reproducing these techniques, which have been standardized and homogeneously applied at our institutions. Objectives: The aim of this study was to review the conjoint experience of three centers and show the mid- and long-term results of bicuspid aortic valve repair. Methods: Between October 1995 and February 2013, 666 patients with bicuspid aortic valve underwent surgery for aortic regurgitation and/or aortic aneurysm. Isolated aortic regurgitation was present in 254 patients, and 412 had aortic aneurysm or dissection. The valve was reconstructed in all the patients (isolated valve repair in 254, "remodelling of the aortic root" in 281, remodelling of the sinotubular junction in 129 and "reimplantation" technique in 2). Results: Mortality was 3/666 (0.5%): 1/254 (0.4%) after isolated valve repair and 2/410 (0.5%) after valve repair plus aortic replacement. In patients with combined procedures (coronary revascularization or mitral/tricuspid valve repair), mortality was 1/77 (1.3%). During follow-up, 12 patients died (10-year survival: 95%). Freedom from reoperation and from aortic valve replacement at 10 and 15 years were 80% and 77%, and 86% and 83%, respectively Freedom from reoperation at 10 years was higher with aortic root (86%) or tubular aorta (84%) replacement, compared with isolated valve repair (74%; p = 0.005). Freedom from any valve-related complication was 80% and 77% at 10 and 15 years, respectively, and was better for valve repair including "remodelling of the aortic root" (87% and 82%) than for isolated repair (77% and 77%; p = 0.04). Conclusions: Bicuspid aortic valve repair is a safe, long-lasting procedure, with a low incidence of mid- and long-term "valve-related complications".

Root remodeling and aortic valve repair for unicuspid aortic valve.

BACKGROUND: Unicuspid aortic valve (UAV) anatomy is occasionally encountered in adolescents or young adults and not infrequently associated with aneurysm of the ascending aorta and aortic root. To manage both defects without aortic valve replacement we propose a combination of remodeling of the aortic root combined with bicuspidization of the UAV. METHODS: Between 1 December 2007 and November 2013, 25 patients (23 males; mean age, 38 ± 12 years; range, 21 to 65 years) with aortic regurgitation as a result of UAV and aortic root dilatation underwent remodeling of the aortic root and bicuspidization of the UAV. The dilated aortic root tissue was resected, leaving the wall adjacent to the normal commissure and at 180 degrees orientation and similar height for the new commissure. The graft was configured to create two symmetric tongues of graft and sutured to the remnants of the aortic root wall. The dysplastic right coronary cusp was resected, and autologous pericardial patches augmented the deficiency of cusp tissue between the left and noncoronary cusps. A suture annuloplasty was used in 20 cases. All patients were followed clinically and echocardiographically at 3, 6, and 12 months and at yearly intervals. Cumulative follow-up was 677 months (mean, 27 ± 18 months). RESULTS: No early or late death occurred. Intraoperative echocardiography revealed minimal or no aortic regurgitation in all patients; at discharge, systolic mean gradient was 6 ± 3 mm Hg. There was no bleeding or thromboembolic event during the follow-up. One patient exhibited endocarditis and underwent reoperation. Two patients experienced relevant recurrent aortic regurgitation for limited suture dehiscence between the patch and the cusp and were reoperated on between 16 and 32 months postoperatively. One patient underwent biologic valve replacement, and two valves were re-repaired. At 5 years, freedom from reoperation and aortic valve replacement was 81% and 91%, respectively. CONCLUSIONS: In the presence of UAV and aortic root dilatation, the concept of valve bicuspidization and root remodeling can be applied with satisfactory hemodynamic results. The hemodynamic function of an aortic valve preserved by this concept is good. If sufficient stability can be achieved, aortic valve replacement can be avoided in young patients with aortic regurgitation caused by UAV and root aneurysm.

Risk factors for prophylactic proximal aortic replacement in the current era.

BACKGROUND: Decision-making in aortic aneurysm involves careful weighing of spontaneous prognosis and operative risk. There is limited recent information regarding operative risk and risk factors using current surgical strategies. METHODS: From 1998 to 2010, 1,221 patients (60 ± 15 years, 67 % male) underwent elective proximal aortic replacement (286 ascending aortic replacement, 699 concomitant root and 387 concomitant arch replacement). Additional cardiac procedures were necessary in 48 %. Previous cardiovascular operations had been performed in 9.6 % (aortic valve 6.3 %, ascending aorta 2.9 %, coronary artery bypass grafting 2.2 %). RESULTS: Early mortality was 4.2 % overall; it was 2.6 % for isolated aortic replacement as primary surgery. In patients younger than 70 years (n = 829), mortality was 2.4 % overall and 1.2 % for isolated and primary surgery; it was 7.9 and 6.4 %, respectively, in patients ≥ 70 years. Mortality was not significantly influenced by root replacement (P = 0.13) or arch replacement (P = 0.27). Multiple logistic regression analysis identified higher age (P < 0.01), chronic aortic dissection (P < 0.01), history of previous cardiovascular surgery (P < 0.01), aortic valve stenosis (P = 0.03), and chronic renal insufficiency (P = 0.03) as independent predictors for increased early mortality. Previous cardiovascular surgery was an independent predictor for increased early mortality in patients younger than 70 (P < 0.01), chronic renal insufficiency was that in patients ≥ 70 years (P < 0.01). CONCLUSIONS: Using contemporary techniques the risk of proximal aortic replacement is low, in particular in younger patients without previous cardiac or aortic surgery. The risk is increased in older patients, in particular with chronic renal insufficiency. This information should be considered in decision-making for prophylactic aortic replacement.

Aortic valve function after bicuspidization of the unicuspid aortic valve.

BACKGROUND: Unicuspid aortic valve (UAV) anatomy leads to dysfunction of the valve in young individuals. We introduced a reconstructive technique of bicuspidizing the UAV. Initially we copied the typical asymmetry of a normal bicuspid aortic valve (BAV) (I), later we created a symmetric BAV (II). This study compared the hemodynamic function of the two designs of a bicuspidized UAV. METHODS: Aortic valve function was studied at rest and during exercise in 28 patients after repair of UAV (group I, n = 8; group II, n = 20). There were no differences among the groups I and II with respect to gender, age, body size, or weight. All patients were in New York Heart Association class I. Six healthy adults served as control individuals. All patients were studied with transthoracic echocardiography between 4 and 65 months postoperatively. Systolic gradients were assessed by continuous wave Doppler while patients were at rest and exercising on a bicycle ergometer. RESULTS: Aortic regurgitation was grade I or less in all patients. Resting gradients were significantly elevated in group I compared with group II and control individuals (group I, peak 33.8 ± 7.8 mm Hg; mean 19.1 ± 5.4 mm Hg; group II, peak 15.8 ± 5.4, mean 8.2 ± 2.8 mm Hg; control individuals, peak 6.0 ± 1.6, mean 3.2 ± 0.8 mm Hg; p < 0.001). At 100 W peak gradients were highest in group I (group I, 62.7 ± 16.7 mm Hg; group II, 28.1 ± 7.6 mm Hg; control individuals, 15.4 ± 4.6 mm Hg; p < 0.001). CONCLUSIONS: Converting a UAV into a symmetric bicuspid design results in adequate valve competence. A symmetric repair design leads to improved systolic aortic valve function at rest and during exercise.

The novel two-dimensional strain reflects improvement and remodeling of left-ventricular function better than conventional echocardiographic parameters after aortic valve repair in pediatric patients.

We aimed to evaluate the outcome and regional and global left-ventricular (LV) function after aortic valve repair in children with congenital aortic valve disease. Thirty-two consecutive patients with a mean age of 12.62 years (4 months to 18 years) undergoing aortic valve repair due to valve stenosis (AS group, n = 21) or aortic regurgitation (AR group, n = 11) were studied during a follow-up period of 12 months regarding change and adaptation of myocardial function using conventional and novel echocardiographic methods, including two-dimensional (2D) strain echocardiogram. Conventional and 2D strain echocardiographic studies were performed and analyzed off-line using commercially available software (EchoPac 6.1.0, GE). Peak aortic valve gradient decreased from 62.04 ± 30.34 mmHg before surgery to 22.80 ± 14.13 mmHg 2 weeks after surgery and to 35.73 ± 22.11 mmHg 12 months after surgery (p = 0.01). The degree of AR decreased significantly to grade 0 in 20 children and to grade I in 12. There was a significant decrease of thickness of the interventricular septum (IVS) and posterior wall resulting in improvement of LV mass index (p = 0.007, p = 0.043, and p = 0.001, respectively). Significant decrease of myocardial thickness was found, especially in the IVS, in the AS group (p = 0.008), and a significant decrease in LV end-diastolic dimension (EDD) was found in the AR group (p = 0.007). 2D strain analysis showed that global peak strain, global systolic strain rate, and global early diastolic strain rates improved significantly for all patients during the study period after aortic valve repair (p < 0.001, p = 0.037, and p = 0.018, respectively). The global strain and strain rates correlated significantly to IVS thickness (r = 0.002 and r = 0.003, respectively), LV mass index (r = 0.02 and r = 0.015, respectively), and EDD (r = 0.26 and r = 0.005, respectively). Aortic valve repair surgery in pediatric patients results in improvement of global and regional systolic and diastolic LV parameters, which was better shown by 2D strain parameters rather than conventional echocardiographic parameters.

Causes and management of aortic valve regurgitation after aortic valve reimplantation.

OBJECTIVE: Recurrent aortic regurgitation can occur after valve-preserving aortic replacement. Little is known about the exact mechanisms of valve failure and the best reoperative strategies. We analyzed our experience with reoperation after aortic valve reimplantation. METHODS: From November 1995 to August 2011, 13 patients (10 men; age, 18-58 years) underwent reoperation for valve failure after aortic valve reimplantation. The reason for reoperation was aortic regurgitation in 11 and endocarditis in 2 after 6 weeks to 13 years. The morphologic causes of regurgitation were cusp prolapse in 6, cusp retraction in 4, cusp perforation in 6, inadequate commissural height in 5, commissural dehiscence in 2, and inadequate valve configuration in 1, alone or combined. The patients were treated by valve replacement (n = 4) or cusp repair (n = 2). In 3 patients, composite replacement of the valve and root was necessary, in 1 with a pulmonary autograft. In 4 patients the aortic valve was spared. All patients were followed up regularly. RESULTS: No patient died early; 1 patient died 4 years after reoperation. One patient required reoperation 2 years after the cusp repair procedure. All patients with repeat valve-preserving root replacement had stable valve function postoperatively. The 5-year survival rate after reoperation was 86% ± 13%. The 5-year rate of freedom from valve-related complications was 78% ± 14%. CONCLUSIONS: Recurrent aortic regurgitation early after aortic valve reimplantation frequently involves cusp prolapse and a low commissural height; later, cusp retraction becomes more important. Reoperation within the first 6 postoperative months allows for preservation of the native aortic valve; however, beyond this period, valve replacement within the graft will mostly be required.

A refined hemispheric model of normal human aortic valve and root geometry.

BACKGROUND: Better understanding of aortic root geometry could improve diagnosis and reconstruction of pathologic aortic valves. In this study, a previous model of hemispheric aortic valve leaflets nested within a cylindrical aorta was refined in humans with normal aortic valves. METHODS: Using 1-mm axial slices, high-resolution computed tomographic angiograms from 10 normal aortic roots were used to generate high-density X-, Y-, and Z-coordinates of valve structures using Mathematica software. Three-dimensional least squares regression analyses of leaflet and sinus coordinates were employed to compare multiple geometric models of aortic valve and root geometry. Shapes and dimensions of all root structures were evaluated and compared. RESULTS: Aortic valve geometry was roughly hemispherical, but the valve base was elliptical (minor-major diameter ratio = .66). Dimensional fits of the leaflet-sinus complexes also were better using ellipsoidal geometry, with taller leaflets than predicted by hemispheres. The commissure between the left and noncoronary cusps was located uniformly at the posterior junction of the base minor diameter and circumference, with the center of the right coronary cusp opposite. The subcommissural post areas flared outward by 5° to 10°, and the volume of the right coronary leaflet-sinus complex was 12.4% and 10.7% larger than the noncoronary cusps and left cusps, respectively. CONCLUSIONS: The normal human aortic valve is an elliptical structure, and ellipsoidal refinements improve representation of leaflet geometry. The left and noncoronary cusps commissure is located posteriorly; the right coronary cusp is located anteriorly. This model could be useful in quantifying pathologic geometry and in engineering devices for aortic valve reconstruction.

Cusp height in aortic valves.

OBJECTIVES: Successful aortic valve repair must normalize cusp and root dimensions. Limited information is available on the normal dimensions of human cusps, in particular the cusp height. METHODS: The cusp height was measured intraoperatively in 621 patients during aortic valve repair procedures. A tricuspid anatomy was present in 329 patients and bicuspid in 286 patients. In addition, patient age, gender, height, weight, preoperative degree of aortic regurgitation, and aortic dimensions were recorded. The data were analyzed for possible interrelation between the cusp height and clinical variables. RESULTS: In the bicuspid valves, the geometric height of the nonfused cusp ranged from 15 to 30 mm (mean, 23.8 ± 2.0). Significant correlations were found between the cusp height and all clinical variables. In the tricuspid valves, the height of the noncoronary cusp ranged from 14 to 28 mm (mean, 20.7 ± 2.2). The height of the left coronary cusp varied from 12 to 25 mm (mean, 20.0 ± 2.1) and that of the right coronary cusp from 12 to 25 mm (mean, 20.0 ± 2.1). The noncoronary cusp was significantly greater than the left and the right coronary cusp (P = .000). No difference was found between the left and right cusps (P = .513). Significant correlations between the geometric height and clinical parameters were found for most clinical variables, excluding the degree of aortic regurgitation. CONCLUSIONS: We found the cusp height was larger than previously published. It shows marked variability and correlates with the clinical variables. These data might serve as the basis for decision making in aortic valve repair.

Early results with annular support in reconstruction of the bicuspid aortic valve.

OBJECTIVE: Repair of the bicuspid aortic valve may be performed in aortic regurgitation and aneurysm. Dilatation of the atrioventricular junction has been identified as a risk factor for repair failure, and we have used suture annuloplasty to correct atrioventricular junction enlargement. The objective was to compare the early results of aortic repair with and without annuloplasty. METHODS: Between November 1995 and January 12, a total of 559 patients were treated with bicuspid aortic valve repair for predominant regurgitation (n = 389), aortic aneurysm (n = 158), or acute dissection (n = 12). Isolated valve repair (aortic valve repair) was performed for aortic valve regurgitation with preserved aortic dimensions (n = 208) and sinotubular junction remodeling plus valve repair for aortic aneurysm and preserved root size (n = 116). Root remodeling was used for dilatation involving the root (n = 235). In 193 patients, dilatation of the atrioventricular junction (>27 mm) was corrected with suture annuloplasty. RESULTS: Hospital mortality was 0.5% (n = 3); 2 patients required pacemaker implantation. Reoperation was necessary for recurrent regurgitation (n = 54) or stenosis (n = 2); 10-year freedom from reoperation was 82% but was inferior after isolated valve repair (70%, P = .007) compared with the 2 other techniques. Application of suture annuloplasty improved 3-year freedom from reoperation after isolated repair (84%) to 92% (P = .07). In all groups, the proportion of patients with no or trivial regurgitation was significantly higher with annuloplasty. CONCLUSIONS: Preservation of the bicuspid aortic valve is feasible in many patients. Long-term stability of the repaired valves is good; the negative impact of a dilated atrioventricular junction can be reduced by suture annuloplasty.

Aortic valve repair--current status, indications, and outcomes.

Aortic valve repair is a new development with old roots. In the past 20 years, marked progress has been made in understanding the normal anatomy of the aortic valve and the interrelation between cusps and root. Aortic dilatation is the single most frequent pathogenetic factor in aortic regurgitation, accompanied by cusp pathology, that is, prolapse or congenital anomaly in most industrialized countries. Frequently, aortic and cusp pathology coexist. Different operative techniques have been established for correction of aortic and cusp pathology. Experience has shown that the combined application of repair procedures will lead to good results if normal valve and cusp configuration is achieved. Some congenital anomalies may require design alteration of the aortic valve. Low-operative mortality rates have been reported consistently. When adequate repair durability is achieved, the incidence of valve-related complications is lower than what has been reported for valve replacement. Aortic valve repair is currently in transition from surgical improvisation to a reproducible operation and an option for many patients with aortic regurgitation. Current research focuses on some special aspects, such as stabilization of the basal ring, ideal material and technique for cusp replacement, and more objective information on ideal valve configuration.