OBJECTIVES The bicuspid aortic valve (BAV) exists in a wide variety of valve phenotypes. The aim of this study was to assess the anatomical characteristics of the different phenotypes and develop a classification system to aid surgical repair. METHODS In 178 consecutive patients operated on for aortic insufficiency or aortic dilatation in 2 centres, 11 anatomical parameters of BAV were measured by echocardiography and intraoperatively. All BAV judged potentially repairable were included in the study. RESULTS Commissural orientation correlated positively with fusion length (R2 = 0.6, P < 0.001) and negatively with non-functional commissure height (R2 = 0.45, P < 0.001). The cohort was divided into 3 groups according to their commissural orientation (type A: symmetrical, 160–180°, n = 73; type B: asymmetrical, 140–159°, n = 74; and type C: very asymmetrical, 120–139°, n = 31). The patterns of cusp fusion, annulus and aortic size were similar among the groups. Fusion length and the geometric height of the cusps decreased from type A to C; non-functional commissure height increased from type A to C (P < 0.05). Patient age increased from type A to type C. Isolated aortic dilatation was more frequent in type A, and severe aortic insufficiency was more frequent in types B and C (P < 0.05). Valve repair techniques and management of commissural orientation varied among the 3 groups (P < 0.05). Aortic valve replacement and residual aortic insufficiency after repair were more frequent in type C (P < 0.05). CONCLUSIONS The BAV phenotypes follow a continuous spectrum that extends from symmetrical to very asymmetrical BAV. We describe the main anatomical parameters (including commissure orientation, length of fusion and non-functional commissure height) and their variation across this spectrum. We propose a new repair-oriented classification system based on those parameters that can be used to predict valve repair techniques. This classification needs further validation with regards to surgical techniques and long-term outcomes.

OBJECTIVES In bicuspid aortic valves (BAV), commissural orientation (CO) varies between 180° and close to 120°. Postoperative CO has a strong effect on repair durability, and different repair approaches have been proposed according to CO; it is thus important for aortic repair. A precise, simple and reproducible determination by preoperative echocardiography would facilitate intraoperative decision-making. We compared 4 different methods of determination of CO in BAV. METHODS Preoperative transoesophageal echocardiograms of 62 patients with BAV were analysed. CO was measured using either the coaptation centre or the geometric centre of the root. The geometric centre of the root was determined through approximation using a circle or an ellipse, or the midpoint of a line between the centre of the non-fused and the fused sinuses. RESULTS The 3 different geometric methods led to almost identical results (interclass coefficient 0.98–0.99), with the line segment being the easiest to use. The use of the coaptation centre was associated with the underestimation of commissural angle of up to 30° compared to the geometric centre; the discrepancy was significant and most pronounced for asymmetric BAV (140–160°; P = 0.005). CONCLUSIONS CO can reproducibly be determined using a line segment between the centre of the non-fused and fused sinuses. The use of the coaptation centre can lead to misleading results, in particular in asymmetric BAVs.

BackgroundThe frequency of concomitant cusp pathology in aortic root aneurysm with or without aortic regurgitation is not well known, and the sensitivity and specificity of two-dimensional trans-oesophageal echocardiography (2D TEE) in its detection has not yet been specified.ObjectivesWe analysed the type and frequency of concomitant cusp alterations in root aneurysm referred for surgery. Sensitivity and specificity of 2D TEE in detecting these alterations were determined.MethodsIn 582 patients (age 56.8±15.4 years, 453 male) with trileaflet aortic valves undergoing root replacement for regurgitation (n=347) or aneurysm (n=235), details of valve morphology were analysed. In a subcohort (n=281), intraoperative TEEs were analysed retrospectively and correlated with the intraoperative findings.ResultsAny cusp pathology was present in 90.9% (prolapse: n=473; retraction: n=30; calcification: n=14; fenestration: n=12), morphologically normal cusps were seen in only 52 patients (8.93%). Valve-sparing surgery was performed in 525 (90.2%) instances, composite replacement in 57 (9.8%). Preoperative TEE correctly identified any postroot repair prolapse in 70.6% and any retraction in 85%. The sensitivity of TEE in detecting any prolapse was 68.6% (specificity of 79.5%). The sensitivity was highest for the right cusp and intermediate for the non-coronary.ConclusionsCusp prolapse is frequent in root aneurysm and trileaflet aortic valves. Prolapse is underdiagnosed by 2D TEE in many cases because pre-existent stretching of cusp tissue is masked by the geometric effects of root dilatation.

Background: Bicuspid aortic valves may be associated with ascending aortic aneurysm, or develop severe aortic regurgitation with variable aortic dilatation. If aortic dilatation involves the root, valve-preserving root replacement is a treatment option, and we prefer root remodeling for this purpose. The objective of this study is to review our experience encompassing 25 years.Methods: Between November 1995 and August 2021, 472 patients (429 male; age 9-80 years; mean 48±13 years) were treated by bicuspid aortic valve repair and root remodeling. Aortic regurgitation was relevant in 322 cases. The primary indication for surgery was aortic regurgitation (n=317), aortic aneurysm (n=143) or acute type A aortic dissection (n=12). In 271 instances, a suture annuloplasty was added. Cusp calcification was present beyond the raphe in 80 cases, and a pericardial patch was used for partial cusp replacement in 44 cases. Follow-up was 92.8% complete with a mean of 71±68 months (median 61 months).Results: Hospital mortality was 0.4% and survival at 20 years was 76.9%. Reoperation was necessary for recurrent aortic regurgitation in 26 patients; nine patients underwent reoperation for stenosis. The overall freedom of reoperation was 90.5% after ten years and 76.6% after 20 years. Annuloplasty was associated with a higher proportion of competent aortic valves at discharge (P=0.001), and had no effect on ten-year freedom from reoperation. The use of a pericardial patch for cusp repair was a predictor for reoperation (P=0.003).The presence of cusp calcification was a predictor for the development of aortic stenosis and reoperation (P=0.032).Conclusions: Bicuspid aortic valve repair combined with root remodeling leads to excellent ten-and 20-year results. Cusp calcification and partial cusp replacement are associated with an increased probability of valve failure requiring reoperation.

Objectives To evaluate the long-term results of remodeling in acute aortic dissection type A (AADA) to define operative risk and root and valve stability. Methods Between October 1995 and December 2018, a total of 352 patients were treated surgically for AADA. Of these, 90 patients with AADA (<2 weeks from onset; age: 57 ± 15 years; 70 males) with a root diameter of >43 to 45 mm (depending on patient size) (48 ± 4.1 mm) underwent aortic root remodeling and were analyzed further. As the control group, we chose the patients with normally sized aortic roots who had been treated by tubular replacement only (n = 227). Other procedures were performed in 35 cases. Results Early mortality was 9% in the remodeling group versus 15% in the tubular ascending aortic replacement (TAR). Actuarial survival at 10 and 15 years was 68 ± 5% and 58.3 ± 6.4%, respectively, in the root remodeling group versus 68 ± 4% and 66 ± 4% in the TAR group (p = 0.99). Freedom from reoperation on the aortic valve or root was 95 ± 3% at 10 years and at 89 ± 6% at 15 years. Freedom from proximal reoperation after TAR at 10 and 15 years was 93 ± 3% and 91 ± 3% (n = 31 patients at risk), respectively, not statistically different from that after remodeling (p = 0.75). Conclusions The long-term stability of aortic root remodeling for enlarged roots with AADA was comparable to TAR preserving a normal aortic root.

Background: Root remodeling is one form of valve-preserving root replacement for aortic regurgitation and root aneurysm. The objective of this review was to summarize our experience with root remodeling encompassing 28 years.Methods: We performed root remodeling in 1,189 patients (76% male, mean age 53±14 years) between October 1995 and September 2022. The original valve morphology was unicuspid in 33 (2%), bicuspid in 472 (40%) and tricuspid in 684 (58%) patients. Fifty-four patients (5%) had Marfan's syndrome. Objective measurement of valve configuration was performed in 804 (77%) and an external suture annuloplasty was added in 524 patients (44%). Cusp repair was performed in 1,047 (88%) patients, most commonly for prolapse (n=972; 82%). Mean follow-up was 6.7±5.5 years [1 month to 28 years]. Follow-up was 95% complete (7,700 patient-years).Results: Survival was 71% at 20 years; freedom from cardiac death was 80%. Freedom from aortic regurgitation ≥2 was 77% at 15 years. Freedom from reoperation was 89% and was higher in tricuspid aortic valves (94%) compared to bicuspid (84%) and unicuspid valves (P<0.001). Since the introduction of effective height measurement, freedom from reoperation has remained stable at 15 years (91%). With the addition of a suture annuloplasty, freedom from reoperation was 94% at 12 years. The difference with or without annuloplasty (91%) was not significant (P=0.949).Conclusions: Root remodeling is a viable option in valve-preserving root replacement. Concomitant cusp prolapse is frequent and can be corrected reproducibly by intraoperative measurement of effective height.The long-term benefit of an annuloplasty still needs to be defined.

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