Long-term Results of Differentiated Anatomic Reconstruction of Bicuspid Aortic Valves

Abstract

IMPORTANCE Bicuspid aortic valve (BAV) repair has been used in limited cohorts, but its long-term results in a large population are unknown.OBJECTIVES To analyze the long-term stability of BAV repair for survival and the factors associated with repair failure and to evaluate whether a differentiated anatomic repair approach may improve repair stability. DESIGN, SETTING, AND PARTICIPANTSIn this case series, 1024 patients underwent BAV repair for aortic regurgitation or aneurysm between October 1995 and June 2018, with a mean (SD) follow-up time of 56 (49) months and maximum follow-up of 271 months. Systematic modifications in technique based on anatomic principles were introduced in 2009 and applied for the last 727 patients. Data were acquired prospectively and analyzed retrospectively.EXPOSURES Repair of BAV with or without concomitant aortic replacement, as well as postoperative clinical and echocardiographic follow-up.MAIN OUTCOMES AND MEASURES Survival and incidence of reoperation or recurrent aortic regurgitation, as well as factors associated with valve repair failure. RESULTS Among the 1024 patients in the study (920 male [89.8%]; mean [SD] age, 47 [13] years [range, 15-86 years]), the survival rate at 15 years was 82.1%. The cumulative incidence of reoperation was 30.7% (95% CI, 22.7%-38.7%) at 15 years. Cusp calcification (subdistribution hazard ratio, 1.78; 95% CI, 1.14-2.77; P = .01), asymmetric commissural orientation (subdistribution hazard ratio, 1.95; 95% CI, 1.02-3.72; P = .04), and use of a pericardial patch for cusp repair (subdistribution hazard ratio, 5.25; 95% CI, 3.52-7.82; P < .001) were associated with time to reoperation. At 10 years, the incidence of reoperation was significantly reduced among patients who received the anatomic repair concept compared with those who had undergone surgery in the earlier period (8.8% vs 24.6%; P < .001). CONCLUSIONS AND RELEVANCEThis study suggests that survival after BAV repair is excellent and that a large proportion of BAV repairs will remain stable. Repair stability can be markedly improved by an anatomic repair concept. Cusp calcification and the need for cusp repair using a patch remain the factors most strongly associated with valve failure. In those instances, valve replacement should be preferred.

Cardiac Surgery 2020 Reviewed

“…Schneider et al 45 published the worldwide largest experience with reconstruction of the aortic valve in patients with bicuspid pathology. The authors illustrate that the introduction of a reproducible concept for valve repair (Schaefers style) results in significant improvement of long-term outcomes.…”

The Ross procedure is an excellent operation in non-repairable aortic regurgitation: insights and techniques

“…Aortic valve repair and aortic valve-sparing operations are the procedures of choice in young and middle-aged adults with aortic regurgitation (AR) (1,2). When performed in expert centers, these operations result in good durability and freedom from valve-related complications, which translate into excellent long-term survival (3,4). When the aortic valve cannot be repaired or spared, replacement options include prosthetic aortic valve replacement (AVR) or pulmonary autograft replacement (i.e., the Ross procedure).…”

Commentary: Methods in observational studies in valve surgery, when time matters

“…Longitudinal analyses are valuable tools to temporally describe the natural history of diseases and to assess whether a particular procedure is able to influence it. As an example, the long-term outcomes of bicuspid aortic valve repair 3 and of the Ross procedure 4 have recently been analyzed with linear mixed-effects modeling, providing a detailed temporal trajectory of the results of these interventions.…”