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Repair of Simple Bicuspid Valve Defects Using Geometric Ring Annuloplasty

Monday, December 8, 2014

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.


Thanks for this pioneering procedure Apart from its magnificent results,i am concerned about future required operation, In case of SBE or developed insufficiency ,does the removal of this ring increase the risk of more aggressive root surgery? Best regards
Of course, more long-term followup and experience will be required, but we currently hypothesize that ring annuloplasty of the aortic valve will be as stable as mitral ring annuloplasty, and in a fully developed state, reoperation should be uncommon. At present, if a leaflet repair broke down, we would attempt re-repair, even by autologous pericardial leaflet replacement (Ann Thorac Surg 2014;98:743–5) and (Ann Thorac Surg 2014;98:2053–60). But if valve replacement is required, ring excision is straight-forward.
The authors should be commended on this innovation that I would deem as Internal Geometrical Annular Remodeling Device. In fact, some degrees of leaflet prolapse should be considered as false prolapse precisely due to the lost of proper geometrical configurations of the aortic root and vetriculo-aortic junction in one hand, and due to the excessive inclination of ventriculo-aortic junction plan in the other hand. Therefore, geometrical restoration of the ventriculo-aortic junction and aortic root is a prerequisite to successful analysis of the leaflets , thereby increasing the rate of repair success. Determination of effective height in BAV was a hazardous task as witnessed by postoperative echo on which a leaflet belly towards LV is often noticed. I noticed no more such a leaflet protrusion on these two postoperative echo: BRAVO I think that is a reflection point in the course of AV repairing techniques

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