Root stabilization of the repaired bicuspid aortic valve: subcommissural annuloplasty versus root reimplantation

At our institution, type I bicuspid aortic valve (BAV) patients with aortic insufficiency (AI) who are candidates for valve preservation are stratified into two groups by aortic root pathology: nonaneurysmal root undergoing primary cusp repair+subcommissural annuloplasty (repair group) vs aneurysmal root undergoing primary cusp repair+root reimplantation (reimplantation group). We report outcomes of this surgical reconstructive strategy for the repaired type I BAV.

A retrospective review was performed of 71 patients with a type I BAV undergoing primary valve repair from 2005 to 2012. The repair group (n=40) underwent annular stabilization by subcommissural annuloplasty, and the reimplantation group (n=31) underwent robust annular stabilization provided by root reimplantation.

Preoperative characteristics and root anatomy were similar, except for increased root dimensions in the reimplantation group (p<0.001). Mortality, stroke, valve reoperation, and pacemaker requirement were zero in both groups. Postoperative peak (19±10 vs 11±5 mm Hg, p<0.001) and mean gradients (10±5 vs 5±3 mm Hg, p<0.001) favored root reimplantation. Freedom from AI greater than 1+ was 100% in both groups. Mean follow-up was 40 months in the reimplantation group and 38 months in the repair group. At 5 years, overall survival was 100% in both groups. Freedom from aortic reoperation and AI exceeding 2+ were similar in both groups. Freedom from AI exceeding 1+ was significantly better in the reimplantation group (92%±6% vs 62%±10%, p=0.03). The 2-year peak (14±6 vs 19±9 mm Hg, p=0.009) and mean (7±4 vs 11±5 mm Hg, p=0.001) gradients favored root reimplantation.

Root stabilization with the reimplantation technique significantly improves the durability of the repaired type I BAV compared with subcommissural annuloplasty. It also provides improved and sustained valve mobility (transvalvular gradients).