A stepwise approach to bicuspid aortic valve repair and reimplantation
Assessment of bicuspid aortic valve before and after repair.
The bicuspid aortic valve (BAV) is the most common congenital cardiac anomaly, affecting around 1% of the population. BAV often leads to aortic insufficiency (AI) at an earlier age and is linked to developmental anomalies in both the heart and aorta, often causing aortic dilation. A large proportion of BAV cases involve aortic and or annular dilatation, and if unaddressed during surgery, this can reduce repair longevity. Proper repair depends on the cusp tissue quality and quantity and commissural orientation, which influences technique selection and repair durability.1
Recent advances in repair techniques for BAV-associated AI and aneurysms have shown excellent long-term outcomes.1,2 This article presents a reproducible stepwise BAV repair technique with illustrations and videos.
Materials and Methods
Our 9-step approach for BAV repair includes narrated videos and illustrations based on clinical cases at our institution. Ethics approval was not required and patient consent was obtained for video recordings.
Results
Step 1: Preoperative Assessment
Preoperative evaluation includes echocardiograms and contrast-enhanced computed tomography. Transthoracic echocardiograms help indicate surgery, whereas transesophageal echocardiograms (TEEs) offer detailed valve views and the regurgitant mechanism. Computed tomography confirms aortic dimensions and detects leaflet calcification. Additional tests like electrocardiograms and coronary angiograms are performed as per routine preoperative assessment (Video 1).1
Step 2: AV Exposure and Assessment
Following distal aortic and right atrial cannulation and institution of cardiopulmonary bypass, myocardial protection is achieved with a combination of retrograde and antegrade cardioplegia. The AV is accessed via a transverse aortotomy. Full thickness commissural sutures expose the valve. BAVs usually have fused cusps, most commonly right-left fusion. A thorough evaluation identifies any cusp thickening, calcification, fenestrations, and mobility, with annular and root assessment crucial to repair planning. Repairability of the AV is dependent on the quantity and quality of the cusp tissue available.3 In particular, mobility of the nonconjoint cusp is critical to valve function and should have a geometric height ≥20 mm. Annular dilation preferentially affects the muscular portion of the aortic annulus and is frequently associated with thinning of the aortic wall in that region (Video 2).
Step 3: Cusp Repair Prereimplantation
Initial cusp repair focuses on cusp preparation without altering its geometry. At the time of an operation, repair is focused on readying the cusp tissue for repair by performing decalcification and shaving. The goal here is to increase and improve coaptation, enable cusp repair after reimplantation, and improve cusp mobility and coaptation (Video 3).
Step 4: Aortic Root Dissection and Coronary Ostia Harvest
External dissection of the aortic root is performed to enable access to the level of the ventriculoaortic junction (VAJ) and basal ring, where the annuloplasty needs to be performed. A deep dissection is essential to allow for a circumferential and robust annuloplasty.4 The deep dissection is particularly important at the right/left commissure where it goes into the right ventricular outflow tract muscle. Coronary button harvest is performed during root dissection. It is important to leave 5 to 7 mm of aortic rim above the cusp insertion to facilitate reimplantation (Video 4).4
Step 5: Graft Sizing in Valve-Sparing Root Replacement
Graft size is determined using the commissural height at the nonleft commissure.5 The height of this commissure represents the size of polyethylene terephthalate graft chosen. If this measurement does not align with a standard graft size, we opt for the next larger size. Typically, the graft sizes used range from 28 to 34 mm (Video 5).
Step 6: Proximal Suture Line and VAJ Annuloplasty
Pledgeted sutures (between 10 and 13 sutures) are placed 1 to 2 mm below the cusp nadir, anchoring the graft to the VAJ. The pledgets are lined up beside each other following a single plane except for the area of the membranous septum, where the suture line comes up a few millimeters to avoid the conduction system. The pledgeted suture line serves to achieve reduction, remodeling, and stabilization of the VAJ and is critical to repair durability.
The sutures are implanted at the base of the graft, dividing it symmetrically into 2 equal halves thereby making the VAJ symmetrical. A small indentation is made at the right/noncommissure to accommodate the limit of external dissection at the membranous septum (Video 6).
Step 7: Reimplantation of the AV
Commissures are reimplanted high within the graft by pulling on the commissural sutures and the graft. A symmetric orientation is preferred for most BAVs, aligning the commissures at 180°. An asymmetric orientation may be preferred for nonregurgitant BAVs that are naturally in asymmetric orientation. A continuous over-and-over suture line from commissure to commissure reimplants the valve following the crown-shaped annulus. The suture line anchors the leaflet insertion point to the polyethylene terephthalate graft to prevent billowing and retain normal geometry of the valve (Video 7).
Step 8: Cusp Repair Postreimplantation
Cusp geometry is reassessed. Effective height ≥10 mm of the nonfused cusp is a marker for stable repair.1 Thickened and calcified areas at the raphe may require partial resection. Prolapse is typically corrected through central plication. Additional repairs, such as fenestration closure, are performed as needed (Video 8).
Step 9: Postrepair Assessment
The coronary ostia are reattached with 5-0 sutures. Root cardioplegia tests with concomitant TEE are used to assess valve function and distal aortic anastomosis completes the procedure. After weaning from cardiopulmonary bypass, TEE confirms valve performance. Markers of late repair failure include residual AI, coaptation length <5 mm, effective height <10 mm, and residual annular dilation (Video 9).
Discussion
BAV repair offers superior outcomes over replacement, with better hemodynamics and lower reintervention rates.1,6,7 Effective repairs stabilize the annulus and restore commissural orientation.6,7 Reimplantation is the preferred approach to BAV repair in most patients because it is the most versatile approach to remodeling the VAJ, sinotubular junction, and commissural orientation to facilitate cusp repair while treating aortic root pathology. However, in select cases of BAV regurgitation without any root dilation, VAJ annuloplasty may be performed using an external polyethylene terephthalate ring or a subcommissural annuloplasty while keeping the coronary arteries intact.8,9
The long-term outcomes of this approach are excellent. At 12-year follow-up in a population in which BAV repair and reimplantation was the surgical approach used, freedom from AV reoperation is around 91%, survival is around 96%, and freedom from recurrent AR >2+ is around 97%.8
Challenges include very asymmetric BAVs, which may complicate repairs, sometimes necessitating replacement.1,7,9 Proper cusp evaluation is essential to determine repair feasibility. A geometric height >20 mm helps assess cusp mobility.1,3 Severe calcification or endocarditis typically requires valve replacement instead of repair.1
Conclusions
This standardized approach to BAV repair technique ensures reproducibility, safety, and long-term success. Systematic application of these principles minimizes variability and facilitates training, ultimately improving patient outcomes and surgical technical dissemination.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.