Commissural geometry and cusp fusion insights to guide bicuspid aortic valve repair

Abstract

Central MessageWe present our new repair-oriented BAV classification, which better describes the complex 3-dimensional geometry/anatomy of BAV and aims at facilitating surgical repair.See Commentaries on pages 93 and 95. We present our new repair-oriented BAV classification, which better describes the complex 3-dimensional geometry/anatomy of BAV and aims at facilitating surgical repair. See Commentaries on pages 93 and 95. Similar to the mitral valve, surgeons nowadays increasingly attempt to repair a regurgitant aortic valve due to its edge over prosthetic aortic valve replacement with better long-term survival, fewer thromboembolic events, and overall improved quality of life.1de Meester C. Pasquet A. Gerber B.L. Vancraeynest D. Noirhomme P. El Khoury G. et al.Valve repair improves the outcome of surgery for chronic severe aortic regurgitation: a propensity score analysis.J Thorac Cardiovasc Surg. 2014; 148: 1913-1920Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar, 2Arabkhani B. Mookhoek A. Di Centa I. Lansac E. Bekkers J.A. De Lind Van Wijngaarden R. et al.Reported outcome after valve-sparing aortic root replacement for aortic root aneurysm: a systematic review and meta-analysis.Ann Thorac Surg. 2015; 100: 1126-1131Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 3Aicher D. Holz A. Feldner S. Kollner V. Schafers H.J. Quality of life after aortic valve surgery: replacement versus reconstruction.J Thorac Cardiovasc Surg. 2011; 142: e19-e24Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 4Mookhoek A. Korteland N.M. Arabkhani B. Di Centa I. Lansac E. Bekkers J.A. et al.Bentall procedure: a systematic review and meta-analysis.Ann Thorac Surg. 2016; 101: 1684-1689Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar, 5Wong C.H.M. Chan J.S.K. Sanli D. Rahimli R. Harky A. Aortic valve repair or replacement in patients with aortic regurgitation: a systematic review and meta-analysis.J Card Surg. 2019; 34: 377-384Crossref PubMed Scopus (13) Google Scholar, 6Chaliki H.P. Mohty D. Avierinos J.F. Scott C.G. Schaff H.V. Tajik A.J. et al.Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function.Circulation. 2002; 106: 2687-2693Crossref PubMed Scopus (168) Google Scholar This is facilitated by a better understanding of the aortic valve and its functional aortic annulus (FAA), basal ring to sinotubular junction (STJ), in addition to Gebrine el Khoury's application of Alain Carpentier's mitral valve principals to the aortic valve.7El Khoury G. Glineur D. Rubay J. Verhelst R. d'Acoz Yd Poncelet A. et al.Functional classification of aortic root/valve abnormalities and their correlation with etiologies and surgical procedures.Curr Opin Cardiol. 2005; 20: 115-121Crossref PubMed Scopus (140) Google Scholar Moreover, aortic valve repair also include bicuspid aortic valves (BAVs), but a repair-oriented classification guiding the surgical approach has been lacking. There have been various descriptive classifications in the past, but from a surgeon's point of view, they do not aid in generating a repair strategy.8Sabet H.Y. Edwards W.D. Tazelaar H.D. Daly R.C. Congenitally bicuspid aortic valves: a surgical pathology study of 542 cases (1991 through 1996) and a literature review of 2,715 additional cases.Mayo Clin Proc. 1999; 74: 14-26Abstract Full Text Full Text PDF PubMed Scopus (311) Google Scholar, 9Sievers H.H. Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens.J Thorac Cardiovasc Surg. 2007; 133: 1226-1233Abstract Full Text Full Text PDF PubMed Scopus (650) Google Scholar, 10Schaefer B.M. Lewin M.B. Stout K.K. Gill E. Prueitt A. Byers P.H. et al.The bicuspid aortic valve: an integrated phenotypic classification of leaflet morphology and aortic root shape.Heart. 2008; 94: 1634-1638Crossref PubMed Scopus (310) Google Scholar, 11Kang J.W. Song H.G. Yang D.H. Baek S. Kim D.H. Song J.M. et al.Association between bicuspid aortic valve phenotype and patterns of valvular dysfunction and bicuspid aortopathy: comprehensive evaluation using MDCT and echocardiography.JACC Cardiovasc Imaging. 2013; 6: 150-161Crossref PubMed Scopus (154) Google Scholar These classifications are too simplistic, only focusing on patterns of cusp fusion and the presence or absence of a raphe (nonfunctional commissure). They do not capture the true 3-dimensional anatomy and variability of the BAV. Nonetheless, our insights into valve phenotypes have evolved, and we now understand that commissural orientation (CO) in BAVs is critical in determining the correct repair strategy, and perhaps also influences outcomes after BAV repair.12Aicher D. Kunihara T. Abou Issa O. Brittner B. Graber S. Schafers H.J. Valve configuration determines long-term results after repair of the bicuspid aortic valve.Circulation. 2011; 123: 178-185Crossref PubMed Scopus (240) Google Scholar,13de Kerchove L. Mastrobuoni S. Froede L. Tamer S. Boodhwani M. van Dyck M. et al.Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification.Eur J Cardiothorac Surg. 2019; 56: 351-359Crossref Scopus (50) Google Scholar Other elements, which also factor into decision making, are length of cusp fusion, height of the nonfunctional commissure (raphe), as well as quality/quantity of cusp tissues and annular dilatation.12Aicher D. Kunihara T. Abou Issa O. Brittner B. Graber S. Schafers H.J. Valve configuration determines long-term results after repair of the bicuspid aortic valve.Circulation. 2011; 123: 178-185Crossref PubMed Scopus (240) Google Scholar, 13de Kerchove L. Mastrobuoni S. Froede L. Tamer S. Boodhwani M. van Dyck M. et al.Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification.Eur J Cardiothorac Surg. 2019; 56: 351-359Crossref Scopus (50) Google Scholar, 14Schafers H.J. Schmied W. Marom G. Aicher D. Cusp height in aortic valves.J Thorac Cardiovasc Surg. 2013; 146: 269-274Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar, 15Schneider U. Feldner S.K. Hofmann C. Schöpe J. Wagenpfeil S. Giebels C. et al.Two decades of experience with root remodeling and valve repair for bicuspid aortic valves.J Thorac Cardiovasc Surg. 2017; 153: S65-S71Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 16Schneider U. Hofmann C. Aicher D. Takahashi H. Miura Y. Schafers H.J. Suture annuloplasty significantly improves the durability of bicuspid aortic valve repair.Ann Thorac Surg. 2017; 103: 504-510Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar In a recent study analyzing BAV anatomy in a large cohort of patients who underwent valve preservation and repair, we observed that BAV phenotypes follow a continuous spectrum, with the CO and thus angulation of leaflet coaptation area, ranging from 120° to 180° (Figure 1).13de Kerchove L. Mastrobuoni S. Froede L. Tamer S. Boodhwani M. van Dyck M. et al.Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification.Eur J Cardiothorac Surg. 2019; 56: 351-359Crossref Scopus (50) Google Scholar For the purpose of repair, we divide this wide spectrum into 3 different phenotypes (Table 1). The most symmetric valves range from 160° to 180°, asymmetric valves from 140° to 159°, and very asymmetric valves from 120° to 139° (Figure 2). The pattern of cusp fusion (right/left in 83%, right/non in 15%, and non/left in 2%) was similarly distributed amongst the 3 phenotype groups. Aortic dilatation (≥45 mm) was present in 47% of symmetric, 37% of asymmetric, and 39% of very asymmetric phenotypes.Table 1BAV phenotypes, anatomy, pathophysiology, and surgical approachBAV phenotypeCommissural orientationRaphe heightCusp fusionProlapseRepairTrue symmetric180°NoneCompleteNone∗In case of root aneurysm without AR, the valve phenotype is generally a true BAV., 1, or 2 cuspsCusp plication(s), 180° repairSymmetric160°-180°Close to BRLong fusionFused cuspCusp plication, 180° repairAsymmetric140°-159°Below STJShort fusionFused cuspRaphe thinning, direct raphe closure, 180° repairVery asymmetric120°-139°Close to STJVery short fusionFused cuspTailored approach Fruste120°-139°At STJVery short fusionFused cuspCommissurotomy, commissure resuspension, commissure reconstruction with patch Fenestrated/Chordal raphe120°-139°Close to or at STJShort fusionFused cuspCord resection, direct raphe closure, 180° repairBAV, Bicuspid aortic valve; BR, basal ring; STJ, sinotubular junction.∗ In case of root aneurysm without AR, the valve phenotype is generally a true BAV. Open table in a new tab Figure 2Repair-oriented classification of bicuspid aortic valve (BAV) phenotypes. Upper panel, Raphe height. Middle panel, Respective commissural orientation and raphe fusion. Lower panel, Surgical view of native valve.View Large Image Figure ViewerDownload (PPT) BAV, Bicuspid aortic valve; BR, basal ring; STJ, sinotubular junction. The aortic annulus in BAV tends to be larger than in trileaflet aortic valves (TAVs), especially in BAV with aortic regurgitation (AR), where it reaches a diameter of 30 mm on average.17Al-Atassi T. Hynes M. Sohmer B. Lam B.K. Mesana T. Boodhwani M. Aortic root geometry in bicuspid aortic insufficiency versus stenosis: implications for valve repair.Eur J Cardiothorac Surg. 2015; 47: e151-e154Crossref PubMed Scopus (7) Google Scholar,18Lansac E. Di Centa I. Sleilaty G. Lejeune S. Berrebi A. Zacek P. et al.Remodeling root repair with an external aortic ring annuloplasty.J Thorac Cardiovasc Surg. 2017; 153: 1033-1042Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Here, it is important to note that the cause of annular dilatation in BAV is mainly secondary to dilation of the anterior septal and thus muscular portion of the ventriculo-aortic junction (VAJ), rather than the posterior fibrous portion of the VAJ. The nonfused cusp in BAV, generally has a higher geometric height compared with the fused cusps, and hence carries most of the available leaflet tissues.13de Kerchove L. Mastrobuoni S. Froede L. Tamer S. Boodhwani M. van Dyck M. et al.Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification.Eur J Cardiothorac Surg. 2019; 56: 351-359Crossref Scopus (50) Google Scholar,19Tamer S. Mastrobuoni S. van Dyck M. Navarra E. Bollen X. Poncelet A. et al.Free margin length and geometric height in aortic root dilatation and leaflet prolapse: implications for aortic valve repair surgery.Eur J Cardiothorac Surg. 2020; 57: 124-132Crossref PubMed Scopus (5) Google Scholar Moreover, it also tends to be the most pliable and mobile, and thus least restrictive cusp in BAV. Accordingly, during repair the nonfused cusp can be utilized to cover more of the aortic orifice if the fused cusp is small, in analogy to the anterior leaflet during mitral valve repair. The cause of regurgitation tends to be the same in all 3 phenotypes. There always appears to be a prolapse of the fused cusps, which in general is more pronounced in the right component of the fused cusp, in asymmetric and very asymmetric phenotypes (in right/left-fusion). A bileaflet prolapse can also occur and is mostly prevalent in the symmetric phenotype. The geometric height of cusps in the symmetric phenotype is also larger, and thereby provides more favorable leaflet tissues for valve repair. Thus, in BAV with AR the mechanism for regurgitation is almost always a prolapse of the fused cusp, with varying degrees of fibrous and calcific degeneration, and an associated annulus dilatation. The nonfused cusps are generally normal and are rarely prolapsing, except in symmetric BAV, or after valve-sparing root replacement for root aneurysm, hence iatrogenic. Via pre- and intraoperative echocardiography, general parameters are established, such as the diameters of the aortic annulus, sinus of Valsalva, STJ, and ascending aorta, as well as the The CO is the on the of the nonfused cusp between 2 the of the aortic root and the 3 and In the CO is on short view in L. Schafers S. Wagenpfeil G. A. Schafers H.J. of commissural orientation in bicuspid aortic J Cardiothorac Surg. 2020; PubMed Scopus Google panel, of commissural orientation on short in view from the Lower panel, Respective surgical view from the valve.View Large Image Figure ViewerDownload (PPT) the determines the pattern of cusp fusion and geometric height of the cusps, and length of raphe fusion. In the height of is to be in true bicuspid valves the height of the nonfunctional commissure is the spectrum of BAV phenotypes, the height of the raphe but always appears than the height of the functional except in BAV (Table 1).13de Kerchove L. Mastrobuoni S. Froede L. Tamer S. Boodhwani M. van Dyck M. et al.Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification.Eur J Cardiothorac Surg. 2019; 56: 351-359Crossref Scopus (50) Google E. or bicuspid aortic valves with very the of bicuspid valve and its be J Cardiol. 2015; Full Text Full Text PDF PubMed Scopus Google Scholar of the an height of the raphe and a of fusion between cusps is in symmetric BAVs we the with a of fusion between cusps and a raphe to the of the fused Kerchove L. Mastrobuoni S. Froede L. Tamer S. Boodhwani M. van Dyck M. et al.Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification.Eur J Cardiothorac Surg. 2019; 56: 351-359Crossref Scopus (50) Google Scholar These are important and our surgical The for a regurgitant BAV are to correct a fused cusp prolapse its and to the repair. cusp can and a prolapse in symmetric BAV, this of and direct be utilized in asymmetric phenotypes without the cusp and the at for is also not a to a fused cusp prolapse in asymmetric D. Kunihara T. Abou Issa O. Brittner B. Graber S. Schafers H.J. Valve configuration determines long-term results after repair of the bicuspid aortic valve.Circulation. 2011; 123: 178-185Crossref PubMed Scopus (240) Google M. Kerchove L. Glineur D. Rubay J. Noirhomme P. et of regurgitant bicuspid aortic valves: a systematic Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar the of tissues in asymmetric BAV, valve is the the at 180° in asymmetric BAV the of the aortic valve orifice by the fused cusp, and in the by the more nonfused The of fused cusp to or direct and cusp with on the Moreover, the of the annulus and root with annuloplasty and root replacement to on the of the fused the 2 decades or to repair a BAV, the general BAV has been sinus and valve-sparing or remodeling E. Kerchove L. Aortic valve repair of the J Cardiothorac Surg. PubMed Scopus Google U. Schmied W. Aicher D. Giebels C. L. Schafers H.J. to valve configuration in bicuspid aortic valve Thorac Surg. 2017; 103: Full Text Full Text PDF PubMed Scopus Google Scholar that a large aortic annulus was a of repair and that the annuloplasty was to a BAV Kerchove L. Boodhwani M. Glineur D. M. Noirhomme P. et al.Valve replacement with the to the durability of bicuspid aortic valve Thorac Cardiovasc Surg. 2011; 142: Full Text Full Text PDF PubMed Scopus Google T. Aicher D. S. H.V. et aortic root geometry and cusp configuration long-term outcome after aortic root Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar annuloplasty such as the external the and the These in of BAV U. Hofmann C. Aicher D. Takahashi H. Miura Y. Schafers H.J. Suture annuloplasty significantly improves the durability of bicuspid aortic valve repair.Ann Thorac Surg. 2017; 103: 504-510Abstract Full Text Full Text PDF PubMed Scopus (74) Google Kerchove L. Boodhwani M. Glineur D. M. Noirhomme P. et al.Valve replacement with the to the durability of bicuspid aortic valve Thorac Cardiovasc Surg. 2011; 142: Full Text Full Text PDF PubMed Scopus Google E. Di Centa I. Sleilaty G. Lejeune S. Berrebi A. et results of external aortic ring annuloplasty for aortic valve repair.Eur J Cardiothorac Surg. 2016; PubMed Scopus Google Scholar the external ring annuloplasty and external root (Figure the left and right ventricular Khoury This for the ring or to be of the and at the of the basal our we have a surgical experience of more than aortic valve In of cases BAV For more than a we have increasingly utilized the to repair most BAV with severe AR or without root This by to aortic root with normal or normal anatomy, can also a BAV with all the present in BAV such as the valve the large annulus, and the For the of BAV repair, we have the into we the 180° Khoury G. Tamer S. Mastrobuoni S. El Khoury G. Kerchove L. Valve root of the aortic Cardiothorac Surg. 2019; PubMed Scopus Google Scholar In the 180° we the BAV geometry into a symmetric configuration with CO of This the basal ring; the valve symmetric symmetric sinus and cusp geometric height as well as bileaflet and a symmetric Thus, and the at This root from to STJ, in valve repair and leaflet 180° has been G. Tamer S. Mastrobuoni S. El Khoury G. Kerchove L. 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