Unicuspid Aortic Valve Repair Using Geometric Ring Annuloplasty
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Bicuspid valves with fusion of both the right-left and right-noncoronary commissures generally are called Sievers type 2 or unicuspid aortic valves (UAV). This anatomy can be difficult to repair with existing techniques.
A 32-year-old athlete with fatigue and class II congestive heart failure presented with severe aortic insufficiency (AI) and early left ventricular dysfunction. Transesophageal echocardiography showed a UAV defect with a large noncoronary sinus. The posterior AI jet was severe from prolapse of the fused right-left cusp.
On inspection, both the right-left and right-noncoronary commissures were severely fused and calcified. Commissurotomies were performed, and the leaflets were gently freed of calcium and fibrous tissue using ultrasonic and sharp debridement. A low-profile bicuspid annuloplasty ring was made of titanium and covered with Dacron, with circular base geometry and two 180 subcommissural posts that flared outward by 10. A 21 mm ring was sutured into the subannular position with nine transannular horizontal mattress sutures to equalize the geometry of the fused right-left and the noncoronary annuli.
After ring placement, the noncoronary leaflet was plicated and raised to a reference 8 mm effective height, and the right-left cleft was closed to raise the right-left fused leaflet free-edge to the same level as the noncoronary cusp.
The lengths and the effective heights of the two reconstructed leaflets were nicely equalized, and the valve opened well. On postrepair echocardiography, the leaflets showed good mobility, with no residual leak, and a 13 mm Hg mean systolic pressure gradient. The patient recovered uneventfully and became asymptomatic. Repeat echocardiography at six months showed a continued 13 mm Hg mean gradient, trivial AI, and normalized left ventricular function.
UAVs can be repaired with two-leaflet reconstructions if the noncoronary sinus is large. The bicuspid annuloplasty ring produces major remodeling of the fused right-left annulus to the size of the noncoronary annulus, facilitating UAV repair.
This video was presented at the 65th Annual Meeting of the Southern Thoracic Surgical Association in Amelia Island, Florida, on November 8, 2018.
- Mazzitelli D, Pfeiffer S, Rankin JS, et al. A regulated trial of bicuspid aortic valve repair supported by geometric ring annuloplasty. Ann Thorac Surg. 2015;99(6):2010-2016.