Bicuspid Aortic Valve Repair and Ascending Aorta Replacement

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The authors present the case of a 66-year-old male who reported peripheral edema over the past month. He was admitted to a primary healthcare hospital, where transthoracic and transesophageal echocardiography revealed a pericardial effusion and dilation of the ascending aorta, associated with moderate aortic regurgitation on a bicuspid aortic valve. Laboratory investigations also identified minor thalassemia and monoclonal gammopathy of undetermined significance (MGUS). The patient was subsequently transferred to the authors’ center. 

During coronary angiography, which revealed no significant lesions, a pericardiocentesis was performed, yielding a frankly bloody evacuation. A CT scan confirmed dilation of the ascending aorta up to 8 cm. The patient was stabilized and scheduled for surgery. 
The operation was performed via median sternotomy. Due to the presence of dense pericardial adhesions, cardiopulmonary bypass was established through cannulation of the right subclavian artery and the percutaneous right femoral vein. A total of 1100 mL of bilateral pleural effusion was evacuated. The pericardium was suspended, and the innominate vein was encircled with a tape. After aortic cross-clamping and administration of antegrade del Nido cardioplegia initially into the aortic root, the aorta was opened. The cardioplegic dose was then completed directly into the coronary ostia. The ascending aorta was completely excised up to the sinotubular junction, and the aortic root was separated from surrounding structures. The free commissures were resuspended to obtain good valve exposure. 

The aortic valve exhibited a partially calcified fusion between the left and right cusps, resulting in a functionally bicuspid morphology with significant regurgitation. The fused commissure was carefully mobilized through gentle decalcification with a blade. Plication of the mobilized cusps was performed using 5-0 Prolene single stitches along the free margin on both sides of the commissural fusion to equalize cusp height. After measuring the sinotubular junction with a Hegar sizer, a 28 mm vascular prosthesis was anastomosed proximally and distally to the aorta using a running suture reinforced with Teflon felt strips. The patient was easily weaned from cardiopulmonary bypass, and the procedure was completed successfully. 

Postoperative echocardiographic evaluation confirmed a competent aortic valve with mild transvalvular gradients and a good left ventricular function. The patient's postoperative course was uneventful, except for the need for hemotransfusion. He was transferred to a rehabilitation unit on postoperative day nine. Histologic examination of the excised aortic tissue revealed elastic fiber fragmentation with regressive myxoid alterations. 

References

1. Ulrich Schneider, Hans-Joachim Schäfers, Repair of the Bicuspid Aortic Valve, Operative Techniques in Thoracic and Cardiovascular Surgery, Volume 22, Issue 2,2017, Pages 91-109, https://doi.org/10.1053/j.optechstcvs.2018.02.003.
2. Ehrlich T, de Kerchove L, Vojacek J, Boodhwani M, El-Hamamsy I, De Paulis R, Lansac E, Bavaria JE, El Khoury G, Schäfers HJ. State-of-the art bicuspid aortic valve repair in 2020. Prog Cardiovasc Dis. 2020 Jul-Aug;63(4):457-464. doi: 10.1016/j.pcad.2020.04.010.

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