Bicuspid aortic valve repair by complete conversion from “raphe'd” (type 1) to “symmetric” (type 0) morphology Thomas G. Gleason, MD The Journal of.

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Presentation transcript:

Bicuspid aortic valve repair by complete conversion from “raphe'd” (type 1) to “symmetric” (type 0) morphology Thomas G. Gleason, MD The Journal of Thoracic and Cardiovascular Surgery Volume 148, Issue 6, Pages 2862-2868.e2 (December 2014) DOI: 10.1016/j.jtcvs.2014.05.021 Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A, The appearance of the pathologic “raphe'd” (type 1) bicuspid aortic valve. B, The repaired valve with its complete conversion to a symmetric (type 0) bicuspid aortic valve. Note that the basilar attachment of the enlarged anterior (previously raphe'd) cusp has been translocated to a position lower in the left ventricular outflow tract, symmetric with the noncoronary (posterior) cusp. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A, An intraoperative photograph of a detached, pathologic raphe'd anterior cusp of a bicuspid aortic valve of the most common phenotype. Note the thickened raphe and nodule of Arantius and the clearly demarcated false commissure, which has also been detached. B, Resection of both the median raphe (including the leading edge with the nodule of Arantius) and the false commissure. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 A, The reconstructed cusp created by sewing together the native residual anterior cusp and a piece of fresh, native pericardium tailored to a size and shape that is precisely symmetric with the noncoronary (posterior) cusp. Note that the leading edge half of the reconstructed cusp is doubly thick, with the native cusp on top of the fabricated pericardial cusp. B, An illustration of the reconstructed anterior cusp, now sewn back into the left ventricular outflow tract, translocating it to a position well inferior (deeper into the left ventricular outflow tract by 6 to 12 mm) from its original annular attachment. It is now symmetrically located relative to the nadir of the noncoronary (posterior) cusp. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 After cusp reconstruction and translocation, (A) annuloplasty is facilitated by placing the primary annular sutures through the base of the heart in a subannular position strictly following the coronet shape of the annulus. These sutures are then placed through the tailored polyester graft in a coronet-shaped pattern on the graft to reduce the subcommissural angle of the annulus. Note the pleats positioned in the graft to create neosinuses. B, The tailored graft then envelopes the entire root apparatus, illustrating the complete conversion to a “symmetric” bicuspid aortic valve. Note the neosinus creation, the annuloplasty, how the primary suture line's position on the graft will dictate how much more acute the subcommissural isosceles triangle will be, and that the entire subcommissural triangle is supported by the graft material. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 A doubly oblique, volume-rendered computed tomographic angiogram after valve repair and valve-sparing root replacement with complete conversion to symmetric anatomy. This valve was converted from a “raphe'd” (type 1) bicuspid aortic valve to a “symmetric” (type 0) bicuspid aortic valve. Note that the 2 cusps are symmetric in size, shape, and position within the left ventricular outflow tract. The neosinus segments are also symmetric in size and shape. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 The most common phenotype of the bicuspid aortic valve (type 1) with a median raphe and false commissure oriented between the anatomic left and right coronary arteries. The posterior (noncoronary) cusp will typically be free of disease. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E2 The normal geometric relationships between the cusp height (h), the commissural height, the annular diameter (d), and the sinus segment diameter (d′). The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E3 A symmetric bicuspid aortic valve with pericardial patch enlargement of its base. Note specifically that only 1 to 2 mm of the residual aorta was preserved, along with the native aortic annulus, with the reimplantation technique used. This allows very precise fixation of the annulus to the graft. Also note the typical position of the pleats to facilitate neosinus creation. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E4 The detachment of the base of the raphe'd cusp up to the commissural attachments. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E5 Apposition of the psreviously cut leading edges of the anterior cusp after resection of the median raphe. Note that the leading edge length of the noncoronary cusp and the tailored anterior cusp are made equivalent at this point by trimming the resection line to create 2 equal length cusps. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E6 A piece of cleaned native pericardium meticulously tailored to match the size and shape of the posterior (noncoronary) cusp. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure E7 Kaplan-Meier survival curves of those who had undergone bicuspid aortic valve repair, valve-sparing root replacement, and hemiarch reconstruction (solid blue line) and those who had undergone complete conversion to a “symmetric” bicuspid valve, with valve-sparing root replacement and hemiarch reconstruction (red dashed line). BAV, Bicuspid aortic valve; VSRR, valve-sparing root replacement. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2862-2868.e2DOI: (10.1016/j.jtcvs.2014.05.021) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions