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Published on: December 11, 2017
Surgical strategy for the bicuspid aortic valve: tricuspidization with cusp extension versus pulmonary autograft
David Michael McMullan1, Guido Oppido, Ben Davies
1Cardiovascular Surgery, Children's National Medical Center, Washington, DC, USA.
Insights
Surgical repair of bicuspid aortic valve disease using tricuspidization with cusp extension (TCE) shows similar reintervention rates to the Ross procedure. While TCE offers satisfactory midterm valve performance, the Ross procedure demonstrates greater long-term valve function stability.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Thoracic Surgery
Background:
- Congenital bicuspid aortic valve is a leading cause of pediatric aortic stenosis/regurgitation.
- Surgical options include repair (thinning, commissurotomy) or replacement (pulmonary autograft/Ross procedure).
- Tricuspidization with cusp extension (TCE) is an alternative repair technique introduced in 1999.
Purpose of the Study:
- To compare midterm clinical outcomes of TCE repair versus the Ross procedure.
- Evaluate the efficacy and durability of TCE repair in pediatric patients.
- Assess reintervention rates and valve function post-surgery.
Main Methods:
- Retrospective analysis of pediatric patients with symptomatic bicuspid aortic valve disease.
- Comparison between TCE repair and Ross procedure (1999-2005).
- Patients were at least 1 year old; median follow-up of 36.4 months.
Main Results:
- 21 patients in TCE group, 25 in Ross group; prior interventions were common.
- Midterm freedom from reintervention was 90% (TCE) vs. 100% (Ross) (P=.39).
- Freedom from moderate dysfunction or reintervention was 66% (TCE) vs. 95% (Ross) (P=.07).
Conclusions:
- Reintervention rates are comparable between TCE and Ross procedures.
- TCE provides satisfactory midterm valve performance.
- The Ross procedure appears to offer greater stability of valve function.
- TCE is a reliable palliative option for symptomatic bicuspid aortic valve disease.
Objective:
The congenitally bicuspid aortic valve is the most common etiologic factor associated with clinically significant aortic stenosis and/or regurgitation in pediatric patients. Beyond infancy, surgical intervention typically involves valve repair with cusp thinning and commissurotomy or valve replacement, primarily with pulmonary autograft in the current era. An aortic valve repair technique using tricuspidization with cusp extension was introduced in 1999. This study compares the midterm clinical outcome in patients undergoing valve repair by tricuspidization with cusp extension with those receiving a pulmonary autograft (Ross).
Methods:
A retrospective study was performed on all consecutive patients with symptomatic bicuspid aortic valve disease who underwent tricuspidization with cusp extension or a Ross procedure between 1999 and 2005. In both groups, all patients were at least 1 year of age at time of the operation.
Results:
During this period, 21 children (median age 12.6 years, range 2.6-18 years) underwent tricuspidization with cusp extension (TCE group) and 25 children (median age 10.2 years, range 11.5 months-20.1 years) underwent the Ross procedure. Prior balloon valvuloplasty was performed in 5 (24%) of the children in the TCE group and 16 (64%) of the children in the Ross group. Prior surgical commissurotomy was performed in 4 (19%) TCE patients and in 9 (36%) Ross patients. During a median follow-up period of 36.4 months (range 2.5 months-7.4 years), 2 (10%) patients in the TCE group required valve-preserving early revision of the repair, 2 (10%) TCE patients required subsequent aortic valve replacement at 16 and 33 months, 1 (4%) Ross patient required subsequent valve repair at 5 years, and 1 (4%) Ross patient underwent cardiac transplantation at 46 months. At 36 months, the actuarial freedom from reintervention on the aortic valve or autograft was 90% in the TCE group, with 11 patients at risk, and 100% in Ross patients, with 13 patients at risk (P = .39); the freedom from moderate valve dysfunction or reintervention was 66% for TCE patients and 95% for Ross patients (P = .07). There were no deaths, and all but 1 Ross patient remain in New York Heart Association class I.
Conclusions:
Reintervention rates in patients undergoing tricuspidization with cusp extension or a primary Ross procedure are similar. Valve performance in the TCE group is satisfactory at midterm follow-up, but the Ross repair appears to provide greater stability of valve function. These results suggest that repair with valve tricuspidization and cusp extension provides reliable palliation of the symptomatic bicuspid aortic valve.
