True Raphe’d

Bicuspid aortic valve (BAV) repair with valve-sparing root replacement (VSRR): the state-of-the-art?

Thomas G. Gleason, M.D., Forozan Navid, M.D.,

Wilson Szeto, M.D., Joseph E. Bavaria, M.D.

University of Pittsburgh and University of Pennsylvania

True BAV with insufficiency

Raphe’d BAV with stenosis

Variable morphological and clinical phenotypes Variable morphological and clinical phenotypes dictate candidacy for preservationdictate candidacy for preservation

Valve-sparing Root Replacement: Valve-sparing Root Replacement: Modified Reimplantation Technique Modified Reimplantation Technique

Gleason, JTCVS 2005;130:601-3.

Valve repair & reimplantation:Valve repair & reimplantation:MRA depicts neosinus creation MRA depicts neosinus creation

Tricuspid Repaired bicuspid

(true)

Repaired bicupsid (raphe)

Aortic valve repair maneuvers used Aortic valve repair maneuvers used

• Central or commissural cusp plicationCentral or commissural cusp plication• Cusp resections (triangular)Cusp resections (triangular)• Pericardial patch-leaflet replacementPericardial patch-leaflet replacement• CommissuroplastyCommissuroplasty• Leading edge reinforcement/shorteningLeading edge reinforcement/shortening• Rudimentary commissural releaseRudimentary commissural release• AnnuloplastyAnnuloplasty

Circulation 2007;116 [suppl I]:I-264-69.

Post AV repair (triangular resection, Post AV repair (triangular resection, commissuroplasty), root replacement, commissuroplasty), root replacement, valve reimplantation.valve reimplantation.

Triangular resection

Commissuroplasty

Post-repair (triangular resection)Post-repair (triangular resection)

2 VSRR techniques used2 VSRR techniques used

• U Pitt 15 cases all using modified reimplantation U Pitt 15 cases all using modified reimplantation technique (tailored graft) (Gleason technique (tailored graft) (Gleason JTCVS 2005;130:601-3.) Root graft sizes 36-42 mmRoot graft sizes 36-42 mm

• Final internal annular diameter 26.5-31 mmFinal internal annular diameter 26.5-31 mm

• 4 pleats used to create 2 sinuses4 pleats used to create 2 sinuses

• 20-26 annular sutures used for annuloplasty20-26 annular sutures used for annuloplasty

• Mean cusp depth 19.4 mmMean cusp depth 19.4 mm

• 2-7 leaflet maneuvers/case (mean 4/case)2-7 leaflet maneuvers/case (mean 4/case)

• HUP 8 cases all using commercial “Valsalva graft” (Cameron Ann Thorac Surg 2006;82:548-53.)

Demographics: 23 patientsDemographics: 23 patients

• Mean age 45.5 (range 33-66)Mean age 45.5 (range 33-66)• 19 male19 male• Procedures performed in all 23 patients:Procedures performed in all 23 patients:

• VSRR 23VSRR 23• Complex AV repair 8Complex AV repair 8• Annuloplasty 15Annuloplasty 15• Hemiarch replacement 21Hemiarch replacement 21• Cox-maze III 1Cox-maze III 1

• Max aortic orthogonal diameter 53.7 mm (range 48-65mm)Max aortic orthogonal diameter 53.7 mm (range 48-65mm)• Aortic regurgitationAortic regurgitation

• 0-trace: 5 pts.0-trace: 5 pts.• 1+ : 8 pts.1+ : 8 pts.• 2+ : 3 pts.2+ : 3 pts.• 3+ : 4 pts.3+ : 4 pts.• 4+ : 3 pts.4+ : 3 pts.

Bicuspid aortic valve repair & Bicuspid aortic valve repair & reimplantation with VSRRreimplantation with VSRR

• 23 VSRR for BAV and TAA23 VSRR for BAV and TAA• 8 with AV repair8 with AV repair• 15 without AV repair 15 without AV repair • 7 true BAV7 true BAV• 16 BAV with raphe16 BAV with raphe

• Follow-up (2-68 mos, Follow-up (2-68 mos, mean 34 mean 34 ±4 mos±4 mos))• 0% mortality0% mortality• 0% stroke0% stroke• 0% PPMs0% PPMs• 0% reoperations0% reoperations• 100% freedom from 100% freedom from ≥ ≥

22+ AR+ AR• 8.6% 1+ AR8.6% 1+ AR• 91% 0-trace AR91% 0-trace AR

Assessment for aortic valve Assessment for aortic valve repair/VSRRrepair/VSRR

A.A. A good repair is better than a good A good repair is better than a good (bio)prosthesis(bio)prosthesis

i.i. No anticoagulationNo anticoagulationii.ii. Potential for longer (indefinite) durabilityPotential for longer (indefinite) durabilityiii.iii. Potential for better hemodynamic profilePotential for better hemodynamic profile

B.B. PitfallsPitfallsi.i. Patient selectionPatient selectionii.ii. Understanding the “pathodynamics” of the Understanding the “pathodynamics” of the

valvevalveiii.iii. Technically more difficultTechnically more difficult