Bicuspid Aortic Valve Impacts the Incidence of Induced Leaflet Prolapse

and Leaflet Repair Following Aortic Valve-Sparring Root Reconstruction

for Aortic Root Aneurysm

Joel Price, Laurent De Kerchove, David Glineur

and Gebrine El Khoury

Cliniques Universitaires Saint Luc, Brussels, Belgium

Background• Reimplantation AVSRR is the

gold-standard treatment for aortic root aneurysm with normal aortic leaflets

• Numerous techniques are described

• All change the native geometry of the functional aortic annulus

• This can potentially result in leaflet prolapse and aortic insufficiency

Purpose

• To define the incidence of induced aortic valve dysfunction following AVSRR for root aneurysm in the absence of AI

• The incidence of induced AI my be different in bicuspid vs tricuspid valves

Methods

• Retrospective study• 1996-2010: 69 patients (14.3%)

underwent AVSRR for aneurysm without significant AI (≤ 1+)

• Subgroup analysis for bicuspid vs tricuspid

End Points

• Incidence of aortic leaflet repair • Need for reinstitution of CPB• increased AI compared to preoperative • Combined endpoint

Variable Mean/Frequencyn=69

Preoperative Characteristics Age (years) 50 ± 16 Male 62 (90%) LVEF (%) 64 ± 7 EDD (mm) 52 ± 6 Max Diameter (mm) 51 ± 6 NYHA Class I 55 (80%) II 12 (17%) III 2 (3%) Prior Cardiac Surgery 8 (12%)

Operative Characteristics Concomitant Procedure 17 (25%) Cross Clamp Time (min) 120 ± 41 CPB Time (min) 133 ± 38

Variable Frequencyn=69

Leaflet Reconstruction 36 (52%)Second Pump Run 1 (1.5%)Increased AI 0 (0%)AI > 1+ at Discharge 1(1.5%)

Variable Bicuspidn=26

Tricuspidn=43

p - Value

Preoperative Characteristics Age (years) 48± 14 51± 18 0.5 Male 39 (91%) 23 (88%) 1.0 LVEF (%) 63 ± 7 66± 9 0.4 EDD (mm) 52 ± 4 52 ± 7 1.0 Max Diameter (mm) 50 ± 8 51± 5 0.7 NYHA Class 0.3 I 19 (73%) 36 (84%) II 7 (27%) 5 (12%) III 0(0%) 2(5%) Prior Cardiac Surgery 0 (0%) 8 (19%) 0.02

Operative Characteristics Concomitant Procedure 2 (8%) 15 (35%) 0.008 Cross Clamp Time (min) 105 ± 30 129 ± 45 0.01 CPB Time (min) 119 ± 28 142± 41 0.008

Combined End-Point

Bicuspid Tricuspid0

10

20

30

40

50

60

70

80

90

100

88%

30%

P< 0.001

%

AI at Discharge

Bicuspid Tricuspid x0

20

40

60

80

100

120

98 100

0

P=0.6

%

Midterm Freedom from AI

Conclusions

• AVSRR performed for root aneurysm without AI can induce leaflet prolapse and AI

• Bicuspid aortic valves are particularly susceptible to induced prolapse and concomitant leaflet repair is very frequently required

• Induced prolapse in tricuspid valves is uncommon

• Surgeons must be prepared to perform concomitant leaflet repair during AVSRR