Type I Bicuspid Aortic Valve
Sparing Root Reimplantation 180°/180° vs. 150°/210° Orientation
Prashanth Vallabhajosyula, MD MS
Division of Cardiovascular Surgery
University of Pennsylvania
Disclosures
None
Talk outline
Discussion points:
• Heterogeneity of type I BAV
• Decision making during intraoperative evaluation
• Technical aspects of geometric orientation of the
aortic neoroot
• Institutional outcomes
Will not be discussing:
• Primary leaflet repair techniques
• Billowing concept
BAV type 0 vs type 1
Type 0
Type I
105
105
150
180
Type 0 (true)
Type 0
Pictures courtesy of G. El‐Khoury
Type 1
(Sievers et al. JTCVS 2007)
180
Type 1 BAV VSRR: Neoroot
Orientation determined at the annulus affects commissure fixation and free margin
What time during surgery do we
make the decision regarding neoroot
leaflet configuration?
Type 1 BAV evaluation and free
margin equalization
Post-repair evaluation
Perimeter assessment
This is when we make a decision about the neoroot orientation
Technical aspects of neoroot orientation
• Preparation for root reimplantation
• Subannular suture placement: orienting the annulus
perimeter in the neoroot
• Fixing the desired leaflet configuration
• Completion of the reimplantation procedure
150°/105°/105° orientation
180°/180° orientation
Institutional outcomes
Demographics and preoperative parameters
BAV 210°/150°
BAV 180°/180°
N
24
21
Age, yrs
43 ± 12
48 ± 11
0.2
Male 21:3
19:2
1.0
Hypertension
11 (46%)
10 (48%)
1.0
Diabetes
4 (16%)
1 (5%)
0.4
Smoker
8 (33%)
7 (33%)
1.0
Ejection fraction, %
59 ± 10
57 ± 7
0.5
LV diastolic diameter, mm
59 ± 10
54 ± 8
0.1
LV systolic diameter, mm
37 ± 7
36 ± 8
0.8
Annulus, mm
30 ± 4
30 ± 4
0.9
Sinotubular junction, mm
45 ± 6
43 ± 6
0.4
Sinus of valsalva, mm
49 ± 5
48 ± 7
0.7
Ascending aorta, mm
46 ± 9
47 ± 9
0.5
0
3 (12%)
0
0.2
1
4 (17%)
1 (5%)
0.4
2
7 (29%)
8 (38%)
0.5
3
4 (17%)
3 (15%)
1.0
4
6 (25%)
9 (43%)
0.2
p
Preoperative Aortic Insufficiency
Intraoperative and postoperative outcomes
BAV 210°/150°
BAV 180°/180°
N
24
21
Cardiopulmonary bypass (CPB), min
295 ± 50
286 ± 56
0.2
Cross clamp, min
240 ± 54
237 ± 45
0.8
Circulatory arrest, min
20 ± 5
17 ± 5
0.1
Arch replacement (%)
17 (71%)
15 (71%)
1.0
MV Repair (%)
0
0
1.0
CABG (%)
1 (4%)
0
1.0
Stroke (%)
0
0
1.0
Reoperation for bleeding (%)
0
0
1.0
Pacemaker placement (%)
0
0
1.0
Mortality (%)
0
1
0.5
No Differences
p
Repair techniques and discharge echo
BAV 210°/150°
BAV 180°/180°
24
21
Primary leaflet repair
Raphe release
24 (100%)
18 (75%)
21 (100%)
11 (52%)
1.0
0.1
Resection with primary closure
4 (16%)
2 (8%)
18 (75%)
6 (25%)
0
5 (12%)
1 (5%)
1 (5%)
16 (76%)
3 (14%)
0
3 (3%)
0.4
BAV 210°/150°
BAV 180°/180°
N
24
21
Freedom from AI >1+ 40 (100%)
21 (100%)
1.0
Peak gradient (mmHg)
11 ± 6
12 ± 5
0.5
Mean gradient (mmHg)
6 ± 3
6 ± 4
1.0
Leaflet Coaptation (mm)
9 ± 2
9 ± 2
1.0
N
Goretex free margin shortening Leaflet plication
Leaflet decalcification
Patch repair
Fenestration repair
p
1.0
1.0
0.5
1.0
0.7
p
Same
Freedom from AI>1+
Summary
• Orienting the neoroot in BAV type 1 VSRR based
on the amount of annular circumference occupied
by each leaflet is a reasonable and safe approach
• Application of this concept may help minimize
billowing, and facilitate a more “natural” leaflet
configuration in the neoroot
• Long term clinical and echocardiographic followup with larger series will be needed to understand
the validity of this concept
Acknowledgements
Caroline Komlo
Kei Wildendorp
Thank you