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Bicuspid Aortic Valve Repair With External Annuloplasty

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posted on 2020-10-20, 21:15 authored by Daniel Navia, Nestor Manuel Clusa, Fernando Piccinini, Juan Mariano Vrancic, Mariano Camporrotondo, Juan Carlos Espinoza, Martin Eric Pairone, Simonetto Bruno


Aortic valve repair is emerging as a beneficial alternative to aortic valve replacement in the treatment of aortic regurgitation, offering young patients the possibility to eliminate the risks of complications associated with prostheses, including thromboembolisms, prosthetic endocarditis, hemorrhages associated with anticoagulation, and the need for reoperation due to structural degeneration of the prosthesis, among others. Patients with enlarged aortic root diameters are well-known candidates for valve-sparing procedures, but isolated aortic regurgitation with normal aortic diameters occurs in 9.5% of the surgical indications of valve surgery in western countries (1).

The reconstructive approach to the aortic valve requires a detailed understanding of its anatomy and functionality and careful evaluation of its pathological lesions in order to effectively treat all the components. Competency of the aortic valve depends on multiple factors, including the diameter of the annulus, sinotubular junction, valve cusps, and commissures. One of the most important predictors of bicuspid and tricuspid aortic valve repair failure is the absence of treating a dilated aortic annulus greater than 25– 28 mm (2).

In this tutorial video, the authors show how they performed an isolated bicuspid aortic valve repair with an external annuloplasty.

Case Presentation

This was a 30-year-old man with no previous history of cardiovascular risk factors. The patient had a 5-year asymptomatic follow-up in another institution and was referred to surgery to the authors’ center when he started with mild dyspnea, by echocardiography left ventricle dilatation with low ejection fraction.

TEE showed a type I bicuspid aortic valve with left and right cusp fusion and severe regurgitation due to anterior cusp prolapse. Left ventricle dilatation with 70 mm diastolic diameter and 50% of ejection fraction.

A CT scan evaluation showed the following aortic diameters:

Aortic Annulus: 30 x 28 mm
Sinus of Valsalva: 34 x 26 mm
Sino tubular Junction: 41 x 37 mm
Tubular Portion: 38 x 38 mm

CT assessment of coronary arteries showed no coronary obstructions or malformations.

Surgical Technique

  1. The aorta was transected above the STJ to improve valve exposure. Anterograde Del Nido cardioplegia was used for myocardial protection.
    Valve Assessment: The authors found type I bicuspid aortic valve with left-right cusp fusion with an incomplete raphe. Prolapse of the fused cusp. Non-fused cusp measurement was 21 mm. Measurement with Hegar dilatators showed a 27 mm annulus.
  2. Dissection of the aortic root down to the sub-annular plane in its entire circumference, including beneath the coronary arteries.
  3. Sub-valvular pledgetted mattress sutures in a U configuration for external annuloplasty were placed as described in the following sites:
    a. at the base of the interleaflet triangle of the left non-commissure
    b. beneath the non-coronary cusp
    c. underneath the left hemicusp
    d. underneath the right hemicusp
    e. second suture beneath the non-coronary cusp, closer to the NC – right commissure
    A sixth external non-pledgetted suture placed the right non-coronary commissure, at the lowest level of the dissection plane to avoid damage to the Bundle of His.
  4. Placement of the external annular ring. The authors used a 27 mm Dacron tube to create a 5 mm width ring that was sized according to the previous Hegar dilatator measured. The ring was passed beneath the U annular sutures and the coronary ostia and tied up with previous sutures.
  5. The left-right cusp raphe was closed with a 6-0 polypropylene suture.
  6. Alignment of the cusp-free edges by traction of commissural sutures at exactly 180 degrees to expose the valve in a symmetrical manner, aiming to create a similar cusp length and correct prolapse by plication of itself. After CBP weaning, TEE evaluation showed an 11 mm cusp coaptation length at the level of the annulus with no residual aortic regurgitation in the doppler mode.

The patient recovery was uneventful and the patient was discharged five days after surgery.


  1. Borger MA, Fedak PWM, Stephens EH, Gleason TG, Girdauskas E, Ikonomidis JS, et al. The American Association for Thoracic Surgery consensus guidelines on bicuspid aortic valve-related aortopathy: Full online-only version. J Thorac Cardiovasc Surg. 2018; 156:e41-e74.
  2. Youssefi P, El-Hamamsy I, Lansac E. Rationale for aortic annuloplasty to standardise aortic valve repair. Ann Cardiothorac Surg. 2019;8(3):322-330.


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