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Ann Thorac Surg 2005;80:304-307
© 2005 The Society of Thoracic Surgeons

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New technology

Pericardial Patch Augmentation for Reconstruction of Incompetent Bicuspid Aortic Valves

^a Department of Thoracic and Cardiovascular Surgery, J. W. Goethe University, Frankfurt am Main, Germany
^b Department of Surgery, University of Vienna, Vienna, Austria

Accepted for publication August 19, 2004.

^_* Address reprint requests to Dr Doss, Department of Thoracic and Cardiovascular Surgery, J. W. Goethe University, Frankfurt am Main, Theodor Stern Kai 7, 60599 Frankfurt am Main, Germany (Email: mirkodoss{at}aol.com).

	Abstract

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PURPOSE: Reoperation rates after repair of bicuspid aortic valves are higher than for mitral valve reconstruction. Secondary changes and small coaptation surface render repair unreliable. Satisfactory results have been reported for patch augmentation for tricuspid aortic valves. We have applied this technique for the repair of bicuspid aortic valves.

DESCRIPTION: Our technique retains the bicuspid morphology of the incompetent aortic valve. A strip of glutaraldehyde-fixed pericardium is sutured to the free edge of the fused leaflet. A large coaptation surface is created, and competence of the bicuspid valve is achieved.

EVALUATION: Sixteen patients underwent reconstruction of their bicuspid aortic valves by pericardial patch augmentation. There were no intraoperative or postoperative deaths. The degree of aortic regurgitation was none to trivial for all patients at a mean follow-up of 3.1 ± 3.4 months. Planimetric effective orifice areas ranged above 2 cm². Mean aortic gradients were 8.2 ± 4.8 mm Hg, and the mean height of coaptation surface was 14.7 ± 2.1 mm.

CONCLUSIONS: The pericardial patch augmentation technique increases coaptation surface, and thus provides reliable early competence of reconstructed bicuspid aortic valves.

	Introduction

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In 1991, Fraser and colleagues [1] published the Cosgrove technique of valvuloplasty for bicuspid valve insufficiency, involving resection of the prolapsing leaflet, annular plication at the commissure, and resection of a raphe when present. The midterm follow-up data of this series, published in 1999 by Casselman and coworkers [2], revealed that this technique was associated with a reoperation rate of 13%, with an additional 6% of patients retaining significant residual aortic regurgitation of grade III to IV.

Our own experiences with the Cosgrove technique confirmed that the intraoperative results were rarely predictable and that there is a high reoperation rate within the first postoperative year [3]. After this early critical phase, the results of the reconstructed native aortic valves were astonishingly stable. This finding spurred us to continue focusing our attention on the reconstruction of bicuspid aortic valves in an attempt to make the technique more reliable. This report documents our experience and early results using the pericardial patch augmentation technique for the reconstruction of incompetent bicuspid aortic valves.

	Principle

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In our experience, bicuspid aortic valves are characterized by a distinct asymmetry. The nonfused leaflet is usually greater in height than the fused leaflet, as its base is often displaced toward the left ventricular outflow tract. On the other hand, the free edge of the fused leaflet is usually greater in size, and prolapse often occurs here. By isolated correction of the excess length of the free edge of the cusp, we can achieve competence of the valve; however, the surface of the coaptation remains marginal. Furthermore, this sort of reconstruction results in a geometrically unfavorable shallow shape of the aortic leaflets. The characteristic belly shape, which is known to display an ideal stress distribution at the lowest tension on the cusps, is not achieved. By augmenting the height of the fused cusp with autologous pericardium, we can improve the results of reconstruction. To overcome the challenges of the bicuspid aortic root, our technique relies on the following principles: (1) the bicuspid morphology of the valve is retained; (2) the free edge of the fused leaflet is enhanced; (3) deliberate overcorrection significantly increases coaptation surface; and (4) the belly shape of the fused leaflet is restored for optimal stress distribution. The principles of our technique are illustrated in Figure 1.

View larger version (23K): [in this window] [in a new window]   Fig 1. Principle of the pericardial patch augmentation technique. (Left) Native bicuspid aortic root with prolapsing fused leaflet and displaced base of the nonfused leaflet. (LVOT = left ventricular outflow tract.) (Right) The free edge of the fused leaflet is enhanced by a glutaraldehyde-fixed pericardium, and competence of the valve is achieved.

	Technique

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To obtain a greater area of leaflet coaptation, a strip of autologous glutaraldehyde-fixed pericardium was used to increase the height of the fused leaflet. Our experience taught us that the ideal length of the strip corresponds to half the circumference of the sinotubular junction. The height of the strip was adjusted according to the desired area of coaptation, but was deliberately left slightly higher than the height of the nonfused leaflet edge. The pericardial strip was sutured to the free edge of the reconstructed aortic leaflet using 5–0 Cardionyl (Peters Laboratorys, Bobigny, France) suture.

The suture line was extended slightly beyond the height of the native commissures and laterally toward the nonfused leaflet. That was done to achieve overlap and optimal coaptation at the commissures (Figs 2, 3, and 4).

View larger version (17K): [in this window] [in a new window]   Fig 2. (Left) Nonfused and (right) prolapsing fused leaflets of native bicuspid root, with separation at the commissure. (LCO = left coronary ostium; RCO = right coronary ostium.)

View larger version (15K): [in this window] [in a new window]   Fig 3. The prolapse of the fused leaflet is corrected by a triangular resection. (LCO = left coronary ostium; RCO = right coronary ostium.)

View larger version (17K): [in this window] [in a new window]   Fig 4. A strip of glutaraldehyde-fixed pericardium is sutured to the free edge of the fused leaflet. The augmented fused leaflet is increased in height to maximize the coaptation surface. At the commissures an overlap is created, thereby ensuring optimal coaptation, and thus addressing the commissural separation. (LCO = left coronary ostium; RCO = right coronary ostium.)

The concomitant dilatation of the ascending aorta was corrected by taking larger bites at the transverse aortotomy, thus achieving a reduction in diameter at the sinotubular junction. To treat the dilatation of the remaining ascending aorta, a longitudinal incision from the aortotomy to the aortic clamp was performed; additionally, an elliptical portion of the aortic wall just proximal of the cross-clamp was resected. A reduction aortoplasty was then carried out with a double layered suture line using a 4–0 Prolene (Ethicon, Somerville, NJ) mattress suture and securing it with an additional 4–0 Prolene running suture (Fig 4). In 4 patients with diameter of the ascending aorta larger than 50 mm, the valve and commissures were resuspended in 32-mm Dacron (C. R. Bard, Haverhill, PA) prostheses.

	Assessment of Reconstruction

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The success of aortic valve repair was assessed intraoperatively by transesophageal echocardiography. Special attention was focused on leaflet motion, valve geometry, coaptation surface, transvalvular gradients, residual aortic regurgitation, and effective orifice area. Additionally, the dimensions of the aortic annulus, sinus of valsalvae, sinotubular junction, and ascending aorta were noted. Trivial to mild residual aortic valve regurgitation was considered a successful repair. As none of the patients had moderate regurgitation or higher, reexploration of the aortic valve to improve the repair was not necessary.

After discharge from hospital, patients were followed up by transthoracic echocardiograms at regular intervals.

	Clinical Experience

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A total of 16 patients underwent reconstruction of their incompetent bicuspid aortic valves using the pericardial patch augmentation technique. There were 14 male and 2 female patients, with a mean age of 34.5 ± 12.9 years. In all patients aortic regurgitation was caused by leaflet prolapse confirmed by preoperative echocardiography and intraoperative inspection of the valve. A raphe of the fused rudimentary commissure was identified in all but 1 patient. Dilatation of the ascending aorta was present in all patients. None of patients had signs of endocarditis in the leaflets or the aortic root at the time of operation.

The mean follow-up was 3.14 ± 3.4 months. All patients were alive and well at follow-up (range, 1 to 12 months). There were no intraoperative or postoperative deaths. Mean cardiopulmonary bypass time was 121 ± 44 minutes, and mean aortic cross clamp time was 84 ± 17 minutes. All patients had an uneventful course on the intensive care ward and were discharged from hospital after a mean stay of 9 ± 3 days.

In all patients, attempted aortic valve reconstruction was successful, with none of the patients requiring intraoperative revision or postoperative reexploration of the reconstructed aortic valve. Other than patch augmentation as descibed above, 9 patients had additional shaving of thickened leaflets, 6 patients had resection of a prolapsing nonfused leaflet, and 3 patients had commissural plication. None of the patients had concomitant cardiac procedures. None of the patients required rexploration for hemorrhage, and there were no conduction disturbances. The degree of aortic regurgitation was trivial at the most, as confirmed by intraoperative transesophageal echocardiography and transthoracic echocardiography at follow-up. The belly shape of the aortic leaflets was restored, and a large coaptation surface was achieved for all patients. Table 1 summarizes the clinical and hemodynamic outcomes of all patients.

	Comment

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The long-term follow-up of this group of patients showed, however, that there was a very low rate of late degenerations. Furthermore, practically none of these patients had valve-related complications [3]. These encouraging late results paired with the recently increased use of autologous pericardium for the replacement of aortic leaflets inspired us to combine both reconstruction techniques [4].

Grinda and coworkers [5] describe their technique of autologous pericardial patch augmentation in the treatment of rheumatic aortic valve disease. Their results serve as clinical proof that this material is very stable, and that if degeneration does occur, then it is only as a consequence of the underlying rheumatic disease.

Results from experimental studies from the development of a new stentless autologouspericardial bioprosthesis serve as further evidence of the durability of this material [6].

The principle of pericardial patch augmentation is overcorrection, which in turn results in increased reliability and in an intraoperative outcome that is more predictable. A benefit in terms of durability has to remain speculative at this time, as no long-term follow-up data are available yet. Owing to the good performance and durability of pericardium in the aortic position, as documented by Duran and colleagues [6], we do not expect an increased degeneration rate. Clinical observations indicate that the bicuspid nature of the valve is associated with an increased incidence of dilatation of the ascending aorta [7–9]. In our group of patients, this pathology was corrected by reduction aortoplasty. Bauer and associates [10] reported good long-term durability data for this method; and because, after reconstruction of the diseased valve, the hemodynamic stimulus for aortic dilatation has been eliminated, we do not expect secondary dilatation to occur.

Our short-term results are encouraging and prove that the concept of pericardial patch augmentation effectively restores competence to bicuspid aortic valves, as documented by perioperative echocardiography. The increased surface of coaptation gives the reconstruction a margin of safety, to accommodate secondary changes in geometry.

Although early and midterm results of alternate forms of aortic valvuloplasty were mediocre, we believe that our modifications of the current techniques are a step toward making this form of treatment more reliable and the outcomes more predictable.

	References

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1. Fraser Jr CD, Wang N, Mee RB, et al. Repair of insufficient bicuspid aortic valves Ann Thorac Surg 1994;58:386-390.[Abstract]
2. Casselman FP, Gillinov AM, Akhrass R, Kasirajan V, Blackstone EH, Cosgrove DM. Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet Eur J Cardiothorac Surg 1999;15:302-308.[Abstract/Free Full Text]
3. Moidl R, Moritz A, Simon P, Kupilik N, Wolner E, Mohl W. Echocardiographic results after repair of incompetent bicuspid aortic valves Ann Thorac Surg 1995;60:669-672.[Abstract/Free Full Text]
4. Gross C, Simon P, Mair R, et al. Autologous tissue cardiac valve for aortic valve replacementtechnical aspects and early results. Ann Thorac Surg 1996;61:1759-1763.[Abstract/Free Full Text]
5. Grinda JM, Latremouille C, Berrebi AJ, et al. Aortic cusp extension valvuloplasty for rheumatic aortic valve diseasemidterm results. Ann Thorac Surg 2002;74:438-443.[Abstract/Free Full Text]
6. Duran CM, Gometza B, Kumar N, Gallo R, Martin-Duran R. Aortic valve replacement with freehand autologous pericardium J Thorac Cardiovasc Surg 1995;110:511-516.[Abstract/Free Full Text]
7. Lindsay Jr J. Coarctation of the aorta, bicuspid aortic valve and abnormal ascending aortic wall Am J Cardiol 1988;61:182-184.[Medline]
8. Bauer M, Pasic M, Meyer R, et al. Morphometric analysis of aortic media in patients with bicuspid and tricuspid aortic valve Ann Thorac Surg 2002;74:58-62.[Abstract/Free Full Text]
9. Burks JM, Illes RW, Keating EC, Lubbe WJ. Ascending aortic aneurysm and dissection in young adults with bicuspid aortic valveimplications for echocardiographic surveillance. Clin Cardiol 1998;21:439-443.[Medline]
10. Bauer M, Pasic M, Schaffarzyk R, et al. Reduction aortoplasty for dilatation of the ascending aorta in patients with bicuspid aortic valve Ann Thorac Surg 2002;73:720-724.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mirko Doss Jeffrey Paul Wood Sven Martens Anton Moritz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Doss, M. Articles by Moritz, A. Search for Related Content PubMed PubMed Citation Articles by Doss, M. Articles by Moritz, A. Related Collections Valve disease Related Article