290. Standardized Technique for Bicuspid Aortic Valve Reimplantation: 180 Degree Commissural Reorientation
*Eric E. Roselli, Robert Borden, *Douglas R. Johnston
Cleveland Clinic, Cleveland, OH
Objective: Bicuspid aortic valve regurgitation associated with annuloaortic ectasia represents two related but distinct pathologies of the aortic valve apparatus, both of which must be addressed to ensure longevity of the surgical repair. We describe a standardized technique for bicuspid aortic valve reimplantation involving reorientation of the commissures to 180 degrees to optimize hemodynamic performance and durability.
Case Video Summary: A 51-year-old male presented with progressively worsening aortic regurgitation associated with annuloaortic ectasia in the setting of a bicuspid valve. Dimensions of the annulus, sinuses, sinotubular junction and mid-ascending aorta were 32mm, 44mm, 37mm and 38mm. Upon inspection intraoperatively, the leaflet tissue was found to be largely normal, with a single raphe between the left and right cusps. The conjoint cusp was debrided and mobilized from the sinuses to allow for proper leaflet excursion. The valve was then sized for a #32 aortic root graft, which was secured to the LVOT with 8 interrupted pledgetted mattress sutures. This was tied over a 25mm Hegar dilator to correct the patient’s annular ectasia. With the graft in position, the left/non-coronary and right/non-coronary commissures were reimplanted into the aortic root graft at an orientation of 180 degrees. The valve was then reimplanted into the tube graft with running suture in the usual fashion. The redundant tissue of the left/right conjoint cusp was plicated to allow for proper coaptation with the non-coronary cusp, creating approximately symmetrical leaflets. Upon separation from cardiopulmonary bypass, the valve demonstrated peak and mean gradients of 18 and 8 mmHg, no regurgitation and full excursion of both leaflets.
Conclusions: For patients with bicuspid aortic valve regurgitation associated with root dilatation and particularly annuloaortic ectasia, this reproducible approach is preferable to limited leaflet repair as it stabilizes the annular diameter to prevent late recurrence of aortic regurgitation. The 180 degree commissural reorientation allows mechanical stresses to be shared equally between the two cusps, potentially maximizing the longevity of the native leaflet tissue.