Bicuspid valve repair outcomes are improved with reduction and stabilization of sinotubular junction and annulus with external annuloplasty

Abstract

Objectives

We investigated long-term outcomes of bicuspid aortic valve (BAV) repair, with external annuloplasty, according to aorta phenotype.

Methods

Between 2003 and 2020, all BAV patients operated for aortic insufficiency (AI) and/or aneurysm were included. Repairs included isolated AI repair with subvalvular ±sinotubular junction (STJ) (single±double) annuloplasty, supra-coronary aorta replacement (±hemi-root remodeling) and root remodeling with external subvalvular ring annuloplasty.

Results

Among 343 patients operated, reparability rate was 81.3% (n=279; age 46±13.3 years). At 10 years (median follow-up: 3.42 years (IQR[1.1,5.8]), survival was 93.9% (n=8 deaths, similar to general population), cumulative incidence of reoperation was 6.2% (n=10), AI grade>2 was 5.8% (n=9), and grade>1 was 23.0% (n=30). BAV repair stabilizing both the annulus and STJ with annuloplasty, compared to non-stabilized STJ repair (single annuloplasty), had lower incidence of reoperation (2.6% vs 22.5%, p=0.0018) and AI grade>2 (1.2% vs 23.6%, p<0.001) at 9 years. Initial commissural angle<160° was not a risk factor for reoperation, compared to angle≥160° if symmetrical repair was achieved (2.7% and 4.1% respectively at 6 years, p=0.85). Multivariable model showed that absence of STJ stabilization (OR=6.7; 95%CI[2.1,20], p=0.001) increased recurrent AI, but not initial commissural angle<160° (OR=1.01; 95%CI[0.39,2.63], p=0.98). Commissures adjusted symmetrically led to lower transvalvular gradient, compared to non-symmetrical repair (8.7mmHg vs 10.2mmHg, p=0.029).

Conclusions

BAV repair, tailored to aorta phenotype, is associated with excellent durable outcomes if both annulus and STJ are reduced and stabilized with external ring annuloplasty. Commissural angle<160° is not associated with reoperation if symmetrical repair is achieved.