Surgical Strategy for the Bicuspid Aortic Valve: Tricuspidization with Leaflet Extension Versus Pulmonary Autograft
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Objective: The congenitally bicuspid aortic valve is the most common etiologic factor associated with important aortic stenosis and/or regurgitation in pediatric patients. Beyond infancy, surgical intervention typically involves valve repair involving leaflet thinning and commissurotomy or valve replacement, most recently primarily using pulmonary autograft. A novel aortic valve repair technique utilizing tricuspidization with leaflet extension (TLE) was introduced in 1999. This study compares the midterm clinical outcome in patients undergoing valve repair with TLE and those receiving pulmonary autograft (Ross).
Methods: A retrospective study performed on all patients with symptomatic bicuspid aortic valve disease who underwent TLE or Ross between 1999 and 2005. All included patients were older than 1 year of age at time of surgery.
Results: During this period 21 children (median age 14.2 years, range 2.6 to 18 years) underwent TLE and 25 children (median age 8.3 years, range 1.0 to 20.1 years) underwent Ross. Prior balloon valvuloplasty was performed in 5 (24%, CL:9-47) of the children in the TLE group and 16 (64%, CL:2-31) of the children in the Ross group. Prior surgical valvotomy was performed in 1 TLE patient (5%, CL:0.1-26) and in 11 Ross patients (44%, CL:65-24). During a median follow-up of 3 years (range 1 month to 5.5 years), 2 patients (10%, CL:0.1-26) required valve-preserving early revision of the TLE repair, one TLE patient (5%, CL:0.1-26) required subsequent pulmonary autograft at 16.6 months, 1 Ross patient (4%, CL:0.1-23) required subsequent valve repair at 5 years. At 36 months, the overall freedom from reintervention on the aortic valve or autograft was 90% in TLE patients, with 9 patients at risk, and 100% in Ross patients, with10 patients at risk (p=0.15). The table below shows the function of the aortic valve at latest follow-up. There were no deaths and all patients remain in NYHA class I.
Conclusions: Reintervention rates in patients undergoing TLE or primary Ross are similar. TLE valve performance is very satisfactory at mid-term follow-up but the Ross appears to provide greater stability of valve function. These results suggest that repair utilizing valve tricuspidization and leaflet extension provides reliable palliation of the aortic valve.
Follow-up - AI ≥ Moderate | 1/24 | 4/20 | p = 0.24 |
Follow-up - AS ≥ Moderate | 0/24 | 2/20 | p = 0.20 |
Follow-up - No AI | 7/24 | 3/20 | p = 0.30 |
Follow-up - No AS | 20/24 | 7/20 | p = 0.02 |
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