Bicuspid aortic valve repair with hemi‐remodeling technique and external ring annuloplasty

Abstract

Background: Current guidelines recommend root replacement when diameter of the sinuses of Valsalva are superior to 45 mm particularly for bicuspid valve. However, in case of tubular aorta aneurysms with moderate root dilatation (40-45 mm diameter), the approach is still debated regarding the increased risk of coronary reimplantation.We present a modified hemi-remodeling aortic repair technique that includes the replacement of the noncoronary sinus, ascending aorta, and valve repair with external ring annuloplasty in patients with bicuspid aortic valve (BAV) and moderately dilated aortic root. Methods: Between 2003 and 2017, 18 patients presenting with left-right BAV and an aortic root diameter at 42.3+/−3.3 mm underwent hemi-root and ascending aorta replacement and aortic valve repair with external annuloplasty.Results: Postoperatively, 16 (88.9%) had no aortic insufficiency (AI) and 2 (11.1%) had grade I AI, no patients had grade III or grade IV AI. Overall survival and freedom from grade II AI at 4 years and freedom from aortic valve-related reoperation were 100%. Conclusion:The standardized modified hemi-remodeling technique we present is a safe and reproducible procedure, with satisfactory durability at follow-up. This technique represents an interesting alternative to full valve sparing root replacement, as it avoids the operative risk of coronary reimplantation, allows shorter crossclamping time and a better exposition on the valve for a symmetrical repair, placing the commissure at 180°, compared with valve sparing root replacement.aneurysm of the ascending aorta, annuloplasty, aortic valve repair, bicuspid aortic valve, valve sparing root replacement | INTRODUCTIONPatients presenting with bicuspid insufficient aortic valve (aortic insufficiency [AI]) and aortic root aneurysms are usually surgically treated by either valve sparing procedures or root replacement when diameter exceeds 45 mm according to the guidelines. 1 In case of tubular aorta aneurysms with moderate root dilatation (between 40 and 44 mm diameter), the approach is still debated, as coronary reimplantion increase operative mortality particularly for the most frequent RL fusion where root dilation is predominant in the Non-Coronary (NC) sinus while right and left sinuses are often not dilated.In this regard, the position of the coronary ostia needs accurate observation, as if the origin of the coronary arteries is above the sinotubular junction (STJ), the aortic root is considered dystrophic and valve sparing operations are indicated. If the coronary ostia is normally positioned, so at the STJ or just below, the replacement of

A surgical case of unruptured giant sinus of Valsalva aneurysm with right ventricular outflow tract stenosis using double closure technique

“…As reported by Wang et al [4][5][6] , residual AI has a poor prognosis often requiring aortic replacement or valvuloplasty, or aortic root replacement. Polos et al 7 performed a valve-sparing root reconstruction procedure(remodeling technique)for an SVA and Carlotta et al 8 conducted an aortic valve repair using a hemi-remodeling technique. However, Wingo et al 9 and Abraiov et al 10 reported in a retrospective study that good results can be obtained by patch closure or aneurysm plication.…”

Valve sparing root replacement — Are we limited in our options?

“…12 Another interesting recent modification that has demonstrated good medium-term patient outcomes in patients with a bicuspid valve and moderate aortic dilatation (40-45 mm) is the hemi-remodeling technique. 13 This method involves the replacement of the noncoronary sinus, ascending aorta, and valve repair with external ring annuloplasty. This technique avoids the operative risk of coronary reimplantation and allows better exposition on the valve for a symmetrical repair and allows shorter cross-clamp times.…”

“…Annular stabilization modifications to the remodeling technique include the David III procedure which adds an external partial annuloplasty (PTFE strip at the base of the noncoronary sinus from trigone to trigone), 7 an external annuloplasty suture, 10 an external annuloplasty ring, 11 and an internal annuloplasty ring 12 . Another interesting recent modification that has demonstrated good medium‐term patient outcomes in patients with a bicuspid valve and moderate aortic dilatation (40–45 mm) is the hemi‐remodeling technique 13 . This method involves the replacement of the noncoronary sinus, ascending aorta, and valve repair with external ring annuloplasty.…”

“…This technique avoids the operative risk of coronary reimplantation and allows better exposition on the valve for a symmetrical repair and allows shorter cross‐clamp times. In a study of 18 patients, 16 (88.9%) were free from aortic insufficiency (AI) and 2 (11.1%) exhibited only grade I AI 13 . Survival, freedom from grade II AI at 4 years, and freedom from aortic valve‐related reoperation was 100% 13 .…”

“…In a study of 18 patients, 16 (88.9%) were free from aortic insufficiency (AI) and 2 (11.1%) exhibited only grade I AI 13 . Survival, freedom from grade II AI at 4 years, and freedom from aortic valve‐related reoperation was 100% 13 . Despite the fact that the original sinuses may go onto develop dilatation, later on, this method of hemi‐remodeling demonstrated satisfactory durability postoperatively and is a reproducible and safe method that could be implemented more commonly as part of the future of VSRR surgery.…”