Ann Thorac Surg 2005;79:1393-1395
© 2005 The Society of Thoracic Surgeons
Case report
Aortic Valve-Sparing Procedure With Cusp Elongation and Free Edge Reinforcement for Bicuspid Aortic Valve
Francois Dagenais, MD*,a,
Richard Bauset, MDa,
Patrick Mathieu, MD
a Department of Cardiovascular Surgery, Québec Heart Institute, Laval Hospital, Sainte-Foy, Quebec, Canada
Accepted for publication October 2, 2003.
* Address reprint requests to Dr Dagenais, Department of Cardiac Surgery, Laval Hospital, 2725 Chemin Sainte-Foy, Sainte-Foy, Quebec G1V 4G5, Canada
francois.dagenais{at}chg.ulaval.ca
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Abstract
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Aortic valve-sparing procedures demonstrate excellent valvular function at midterm. Recently authors have reported acceptable early results with aortic valve-sparing procedures on patients with regurgitant bicuspid valves. We report the case of a novel procedure to preserve bicuspid valves with a calcified raphe and root dilatation. This procedure includes raphe excision, pericardial patch elongation, free edge leaflet reinforcement, and a root reimplantation valve-sparing procedure.
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Introduction
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Aortic valve-sparing procedures have shown good early and midterm results in patients with tricuspid aortic valves [1]. Aortic valve-sparing procedures for bicuspid aortic valves remain less investigated and controversial. Although authors report good early results, others have observed early failures [2, 3]. Operative technique may require raphe excision and cusp closure. We report a modified technique when raphe excision does not allow primary closure.
A 41-year-old man was referred for severe aortic regurgitation on a bicuspid aortic valve with root enlargement (48 mm at the sinotubular junction). At operation, a bicuspid valve with an enlarged annulus (33 mm) was observed. The valve was grossly normal other than a calcified raphe (Fig 1). A rudimentary commissure of the conjoined leaflet was present with the raphe extending toward the leaflet margin. Although the free margin of the fused leaflet seemed to be elongated, a relative prolapse of the nonconjoined leaflet was noticed owing to the downward restriction induced by the calcified raphe. Raphe excision was carried out. Owing to cusp restriction, primary closure of the edges of the excised raphe was impossible. To lengthen the free edge of the cusp, a "V"-shaped untanned autologous pericardial patch was sutured with a running 5-0 Prolene (Ethicon, Somerville, NJ) to replace the excised raphe (Fig 2). To enhance leaflet coaptation and correct the nonconjoined cusp prolapse, a running in and out 6-0 Goretex (Gore Medical, Flagstaff, AZ) was sutured on the free edge of each leaflet from one commissure to the other (Fig 3). The valve-sparing procedure was completed by suturing a 28-mm Dacron graft to the annulus (reimplantation technique). Commissures were re-suspended within the graft, including the nondominant commissure. Postoperative echocardiography showed no aortic regurgitation and a mean gradient of 10 mm Hg. Follow-up at 18 months showed comparable echocardiographic findings.
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Fig 2. Raphe excised and cusp elongation being achieved with a "prime"-shaped autologous pericardial patch.
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Comment
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A bicuspid aortic valve is the most commonly recognized congenital cardiac malformation. Prevalence is estimated to be between 1% and 2% of the population. The natural history of bicuspid valves has shown that up to 60% of patients may live a normal life without requiring intervention on the aortic valve [4]. However, bicuspid valves may calcify and lead to aortic stenosis.
On the other hand, severe aortic regurgitation related to cusp prolapse without annular dilatation may be repaired solely by leaflet plasty. In another subgroup of patients with bicuspid aortic valves with or without cusp prolapse, concomitant aortic root dilatation may lead to aortic regurgitation. Recent reports have investigated valve-sparing procedures for this subgroup of patients. Operative technique focuses on cusp re-suspension with or without raphe excision. Because the prolapse in a bicuspid valve is mostly related to a lengthened conjoined leaflet, raphe excision and primary closure will correct this anomaly in the majority of circumstances.
Conversely, Schäfers and colleagues [2] reported on 16 patients with valve-sparing procedures for bicuspid valve patients and suggested that correcting the prolapsed fused leaflet by simply adding plication sutures, thus preserving the raphe. We personally think that the raphe should be excised owing to its propensity to calcify with time as reported by Ward [5]. However, excision of a diseasedraphe with restricted cusp mobility (as observed in our case) may obviate primary closure. To remedy the loss of cusp substance after raphe excision in such circumstances, we describe a technique to increase the free edge cusp length by interposing a "V"-shaped autologous pericardial patch (Medtronic, Minneapolis, MN) in the raphe position.
Duran and colleagues [6] have reported excellent late outcome in patients with aortic valve repair using autologous pericardium. Furthermore, as suggested by David and colleagues [1], the free edge of both leaflets were reinforced with a 6-0 Goretex suture to correct cusp prolapse and enhance cusp coaptation.
On the other hand, Cosgrove and Fraser [7] have suggested simply adding annuloplasty sutures to enhance cusp coaptation. In our case report, cusp apposition was further increased by reducing the annular circumference by suturing a 28-mm Dacron graft to the annulus. This step is crucial to correct annular dilatation and prevent further dilatation in patients with bicuspid aortic valves and combined aortic root ectasia. We think that use of the remodeling Yacoub technique in such a setting may jeopardize long-term outcome due to a significant probability of recurrent aortic regurgitation due to progressive annular dilatation. Using the reimplantation technique to further enhance leaflet coaptation and prevent annular dilatation may be compared with the use of an annuloplasty ring in mitral valve repair procedures. Furthermore, reconstructing the asymmetric root geometry in patients with bicuspid valves is definitely more challenging, especially if using a modified Yacoub remodeling valve-sparing technique. The height of the two normal commissures and the rudimentary commisure has to be taken into account during the root reconstruction. In our case report, the rudimentary commissure was resuspended within the graft at a lower level than the two normal commissures to reestablish normal root anatomy. Results of bicuspid valve repair remain controversial.
Conversely, the Cleveland Clinic group reported up to 25% of significant aortic regurgitation or necessity of reoperation at 5 years after repair for bicuspid aortic valve without a valve-sparing procedure [8]. Reoperation was mainly linked to the presence of residual aortic regurgitation on immediate postoperative echocardiography. The issue of failure related to aortic root dilatation was not discussed.
On the other hand, other authors have reported excellent early outcome for bicuspid valve preservation using a valve-sparing procedure [2, 9]. However, the extensive cusp plasty described in our case report significantly increases technical difficulties and may jeopardize long-term outcome. However, the excellent valve function (as documented on follow-ups) shows acceptable early outcomes of this procedure. Interestingly, in patients with bicuspid or tricuspid aortic valves, valve-sparing procedures have not been found to be an increased risk of failure when cusp plasty was added to the procedure [10].
In conclusion, we describe a modified technique to preserve bicuspid valves in presence of a calcified raphe and root dilatation. The procedure includes raphe excision, pericardial patch enlargement, free edge reinforcement, and root reimplantation. Although the aortic valve-sparing procedure is promising for patients with bicuspid aortic valves and root dilatation, long-term follow-up is essential to ascertain good late outcome in this young age population of patients.
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References
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- David TE, Armstrong S, Ivanov J, Webb GD. Aortic valve sparing operations: an update. Ann Thorac Surg. 1999;67:1840–1842[Abstract/Free Full Text]
- Schäfers HJ, Langer F, Aicher D, et al. Remodeling of the aortic root and reconstruction of the bicuspid aortic valve. Ann Thorac Surg. 2000;70:542–546[Abstract/Free Full Text]
- Sarsam MA, Yacoub M. Remodeling of the aortic valve annulus. J Thorac Cardiovasc Surg. 1993;105:435–438[Abstract]
- Mills P, Leech G, Davies M, et al. The natural history of a non-stenotic bicuspid aortic valve. Br Heart J. 1978;40:951–957[Abstract/Free Full Text]
- Ward C. Clinical significance of the bicuspid aortic valve. Heart. 2000;83:81–85[Free Full Text]
- Duran CMG, Gometza B, Kumar N, et al. From cusp extension to valve replacement with stentless pericardium. Ann Thorac Surg. 1995;60:S428–S432
- Cosgrove DM, Fraser CD. Aortic valve repair. Operative techniques. Cardiac Thorac Surg. 1996;1:30–37
- Casselman FP, Gillinov AM, Akhrass R, et al. Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet. Eur J Cardiothorac Surg. 1999;15:302–308[Abstract/Free Full Text]
- Suematsu Y, Morota T, Kubota H, et al. Valve-sparing operations for aortic root aneurysm in patients with bicuspid aortic valve. Ann Thorac Surg. 2002;74:907–908[Abstract/Free Full Text]
- Schäfers HJ, Aicher D, Langer F. Correction of leaflet prolapse in valve-preserving aortic replacement: pushing the limits? Ann Thorac Surg. 2002;74:S1762–S1764[Abstract/Free Full Text]
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Abstract
Introduction
