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Bicuspid aortic valve (BAV) repair with valve-sparing root replacement (VSRR): the state-of-the-art?. True. Raphe’d. Thomas G. Gleason, M.D., Forozan Navid, M.D., Wilson Szeto, M.D., Joseph E. Bavaria, M.D. University of Pittsburgh and University of Pennsylvania.

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  1. Bicuspid aortic valve (BAV) repair with valve-sparing root replacement (VSRR): the state-of-the-art? True Raphe’d Thomas G. Gleason, M.D., Forozan Navid, M.D., Wilson Szeto, M.D., Joseph E. Bavaria, M.D. University of Pittsburgh and University of Pennsylvania

  2. Variable morphological and clinical phenotypes dictate candidacy for preservation Raphe’d BAV with stenosis True BAV with insufficiency

  3. Valve-sparing Root Replacement: Modified Reimplantation Technique Gleason, JTCVS 2005;130:601-3.

  4. Valve repair & reimplantation:MRA depicts neosinus creation Tricuspid Repaired bicuspid (true) Repaired bicupsid (raphe)

  5. Aortic valve repair maneuvers used • Central or commissural cusp plication • Cusp resections (triangular) • Pericardial patch-leaflet replacement • Commissuroplasty • Leading edge reinforcement/shortening • Rudimentary commissural release • Annuloplasty

  6. Circulation 2007;116 [suppl I]:I-264-69.

  7. Post AV repair (triangular resection, commissuroplasty), root replacement, valve reimplantation. Commissuroplasty Triangular resection

  8. Post-repair (triangular resection)

  9. 2 VSRR techniques used • U Pitt 15 cases all using modified reimplantation technique (tailored graft) (Gleason JTCVS 2005;130:601-3.) Root graft sizes 36-42 mm • Final internal annular diameter 26.5-31 mm • 4 pleats used to create 2 sinuses • 20-26 annular sutures used for annuloplasty • Mean cusp depth 19.4 mm • 2-7 leaflet maneuvers/case (mean 4/case) • HUP 8 cases all using commercial “Valsalva graft” (Cameron Ann Thorac Surg 2006;82:548-53.)

  10. Demographics: 23 patients • Mean age 45.5 (range 33-66) • 19 male • Procedures performed in all 23 patients: • VSRR 23 • Complex AV repair 8 • Annuloplasty 15 • Hemiarch replacement 21 • Cox-maze III 1 • Max aortic orthogonal diameter 53.7 mm (range 48-65mm) • Aortic regurgitation • 0-trace: 5 pts. • 1+ : 8 pts. • 2+ : 3 pts. • 3+ : 4 pts. • 4+ : 3 pts.

  11. 23 VSRR for BAV and TAA 8 with AV repair 15 without AV repair 7 true BAV 16 BAV with raphe Follow-up (2-68 mos, mean 34 ±4 mos) 0% mortality 0% stroke 0% PPMs 0% reoperations 100% freedom from ≥ 2+ AR 8.6% 1+ AR 91% 0-trace AR Bicuspid aortic valve repair & reimplantation with VSRR

  12. Assessment for aortic valve repair/VSRR • A good repair is better than a good (bio)prosthesis • No anticoagulation • Potential for longer (indefinite) durability • Potential for better hemodynamic profile • Pitfalls • Patient selection • Understanding the “pathodynamics” of the valve • Technically more difficult

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