Repair of Simple Bicuspid Valve Defects Using Geometric Ring Annuloplasty

Originally presented at the 2014 STSA Annual Meeting

Objectives: The repair of bicuspid valves with aortic insufficiency has become routine and leaflet reconstruction techniques are now standardized. Long-term results are good, but some patients experience late-repair failure due to progressive annular dilatation. This video illustrates bicuspid annular stabilization during repair using a geometric annuloplasty ring that is currently under investigation in Europe (NCT02071849).

Methods: An internal bicuspid annuloplasty ring was developed with circular base geometry and two 10-15 degree outwardly flaring subcommissural posts, positioned 180 degrees opposite on the circumference. This video shows the technique of surgical ring placement into the valve annulus, and bicuspid leaflet repair, in two patients with simple bicuspid defects. The first patient had a Sievers Type 0 valve with R-L fusion, no cleft, and only moderate aortic insufficiency. The valve was repaired during grafting of an ascending aortic aneurysm. The second patient had a Sievers Type I valve with R-L fusion, a moderate cleft, and severe aortic insufficiency. Both were repaired with #23 ring annuloplasties and standard leaflet reconstruction techniques.

Results: In both patients, ring annuloplasty was performed initially, which moved the sinus-to-sinus dimension toward the midline, and facilitated leaflet coaptation. Patient 1 required only minor leaflet plication. Patient 2 had closure of a moderate fused leaflet cleft, in addition to leaflet plication. Both patients achieved complete competence after repair, and exhibited low trans-valvular gradients. For patients with more difficult leaflet disease, such as calcified leaflets or unicuspid valves, complete autologous pericardial leaflet replacement is performed.

Conclusions: Bicuspid ring annuloplasty is a simple and expeditious method of annular stabilization during valve repair and does not require deep aortic root dissection. Major annular remodeling converts the valve to 50%-50% annular geometry, and contributes to improved leaflet coaptation. Geometric ring annuloplasty could improve the early and late results of simple bicuspid valve repair associated with aortic insufficiency.

Copyright 2014, used with permission from the Southern Thoracic Surgical Association. All rights reserved.