Root Stabilization of the Repaired Bicuspid Aortic Valve: Subcommissural Annuloplasty Versus Root Reimplantation Prashanth Vallabhajosyula, MD, MS, Caroline.

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Root Stabilization of the Repaired Bicuspid Aortic Valve: Subcommissural Annuloplasty Versus Root Reimplantation Prashanth Vallabhajosyula, MD, MS, Caroline Komlo, BS, Wilson Y. Szeto, MD, Tyler J. Wallen, DO, Nimesh Desai, MD, PhD, Joseph E. Bavaria, MD The Annals of Thoracic Surgery Volume 97, Issue 4, Pages 1227-1234 (April 2014) DOI: 10.1016/j.athoracsur.2013.10.071 Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Root stabilization techniques in the context of the repaired type I bicuspid aortic valve (BAV) are shown. (A) To achieve annular reduction of the repaired BAV with subcommissural annuloplasty, vertical interrupted sutures with pledgets are placed in the interleaflet triangle of each commissure and tied down. Care must be taken not to restrict the mobility of the leaflets when these stitches are placed. Subcommissural stitches are not placed at the pseudocommissure. With root reimplantation, the repaired BAV is reconstructed into a Valsalva graft neoroot, and the coronary buttons are reimplanted into the neoroot. This achieves more a symmetric and circumferential annular reduction than subcommissural annuloplasty. (B) In type I BAV root reimplantation, the aortic neoroot can be configured in two geometric orientations. In the 180-180 degree orientation, the conjoint and nonconjoint cusps occupy an equal surface area at the annular plane. In the 150-210 degree orientation, the conjoint cusp occupies 7/12 of annular circumference and valve area, and the nonconjoint cusp occupies the remainder 5/12 area and circumference. (LCA = left coronary artery; LCC = left coronary cusp; NCC = noncoronary cusp; RCA = right coronary artery; RCC = right coronary cusp.) The Annals of Thoracic Surgery 2014 97, 1227-1234DOI: (10.1016/j.athoracsur.2013.10.071) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Kaplan-Meier survival curves comparing repair (dashed line) vs reimplantation (solid line) groups. (A) Freedom from aortic reoperation (p = 0.38). (B) Freedom from AI greater than 2+ (p = 0.53). (C) Freedom from AI greater than 1+ (p = 0.03). The Annals of Thoracic Surgery 2014 97, 1227-1234DOI: (10.1016/j.athoracsur.2013.10.071) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Proposed root stabilization algorithm for bicuspid aortic valve aortic insufficiency undergoing primary cusp repair. (STJ = sinotubular junction.) The Annals of Thoracic Surgery 2014 97, 1227-1234DOI: (10.1016/j.athoracsur.2013.10.071) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions