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Editorial
BAV repair algorithm: 20 years experience
Algoritmo reparación válvula aórtica bicúspide tras 20 años de experiencia
Marek J. Jasinskia,b
a Clinical Department Cardiac Surgery, Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
b Children's Memorial Pediatric Health Institute, Warsaw, Poland
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The presence of BAV is associated with a high incidence of valve dysfunction&#44; proximal aortic dilatation&#44; and an increased incidence of acute aortic events&#46; Current recommendations include an earlier threshold for surgical correction and the use of valve-sparing operations in patients with bicuspid valve insufficiency&#46; However&#44; the reported durability of BAV repair does not appear to be as good as for the tricuspid aortic valve&#46; It may be related to connective tissue disorder&#44; which is often the main feature of BAV&#46; The progressive annular dilatation caused by annulo-aortic ectasia may affect the repair stability&#44; but precise data are still lacking&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">17 years long term follow-up of 206 patients I performed BAV repair showed that circumferential annuloplasty significantly improved repair durability&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;2</span></a> It has also confirmed the preoperative phenotype as a significant predictor for freedom from redo operation&#46; It has recently been suggested that symmetrical preoperative commissural orientation imposes better postoperative durability&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> It was confirmed with my studies comparing different techniques of annuloplasty&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;4</span></a> In spite of inferior durability due to progression of recurrent moderate AR and higher gradients in subcomissural annuloplasty group&#44; they may still present good clinical outcome still a safe and repeatable technique provided properly executed during operation&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> Both conclusions are fundament of my technique with two essential elements which is a annuloplasty&#44; preferably in circular fashion and aiming at 180&#176; symmetry postoperatively&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">All the operations followed a similar protocol described previously&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6&#8211;8</span></a> They are presented online in MMCTS format&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9&#44;10</span></a> Briefly&#44; in all cases&#44; the chest was opened via median sternotomy&#46; A standard-setting cardiopulmonary bypass was initiated&#44; and the myocardium was protected with either blood or del Nido cardioplegia&#46; First&#44; alignment of leaflets&#44; the effective and geometric height of each leaflet&#46; The central leaflet coaptation and individual leaflet prolapse were evaluated by measuring effective coaptation or relative to root leaflet height&#46; Secondly&#44; the relative lengths of the leaflet free margins were assessed by suturing two noduli Arantii together and identifying leaflets with excessively stretched&#44; elongated segments producing prolapse&#46; Then&#44; the fused leaflet anatomy was evaluated&#46; In the case of concomitant bicuspid aortopathy&#44; either aortic root reimplantation or STJ remodeling with supracoronary ascending aortic replacement for ascending aortic diameter &#8805;45<span class="elsevierStyleHsp" style=""></span>mm were performed&#46; Sizing of the aortic graft&#44; and the external ring is based on the height of leaflets and the height of the subcommissural triangle between the left and non-coronary sinuses and the non-coronary leaflet&#44; according to the El-Khoury and David-Feindel formulas&#46; The commissures are located at 160&#8211;180&#176; angles during root remodeling or valve reimplantation to maintain the symmetry of the repaired BAV and to enhance the fused leaflet mobility&#46; In internal annuloplasty&#44; the non-fused leaflet serves as a reference&#44; and its free-edge length &#40;FEL&#41; is measured with a ball sizer that predicts required ring diameter &#40;<span class="elsevierStyleItalic">D</span>&#41; as&#58; <span class="elsevierStyleItalic">D</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>FEL&#47;1&#46;5&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The enlarged aortic annulus is stabilized using either subcommissural plication or annuloplasty &#40;SCA&#41; or circumferential annuloplasty techniques&#58; the internal ring annuloplasty or external annuloplasty &#40;EA&#41;&#46; SCA was performed with two braided 2-0 pledgeted stitches to narrow two subcommissural triangles&#44; in its upper half to avoid gradient&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">12&#44;13</span></a> Internal ring annuloplasty for bicuspid aortic valve is commercially available as HAART 200&#8482;&#46; The bicuspid ring has circular base geometry with 180&#176; sub-commissural posts that flare outward by 10&#176;&#46; The ring is sutured to the valve annulus with 9 trans-annular horizontal mattress sutures &#8211; shown in blue&#46; The ring is sized to keep inter-commissural distance constant&#44; but it moves the dilated sinuses centrally to improve leaflet coaptation&#46; Due to 180&#176; symmetry&#44; the ring is able to remodel the annulus by its diameter reduction as well as increase fused leaflet mobility&#46; The EA procedure consisted of the placement of a circular line of six to eight interrupted pledgeted 2-0 braided sutures from inside of the aorta&#44; with another five along the fibrotic part of the annulus and additional ones at the bottom of the third subcommissural triangle and leaflet nadir&#44; supported by a Dacron ring placed from the outside&#46; In other circumstances&#44; EA was part of the reimplantation procedure&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> or when used as a partial supporting ring of fibrotic annulus &#40;55&#37; of circumference&#41;&#44; supported with internal goretex suture annuloplasty to avoid deep anterior dissection and coronary mobilization&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The sinotubular junction &#40;STJ&#41; remodeling was part of the supracoronary Dacron graft implantation&#46; The sizing of the Dacron graft in EA cases were identical&#46; However when internal annuloplasty used&#44; STJ is determined by ring size &#43;7<span class="elsevierStyleHsp" style=""></span>mm&#46; Aorta distal to anastomosis is further secured by wrapping inside the same dacron prosthesis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">All patients are having various aortic annulus and aortic root procedures&#44; including ones without any type of annuloplasty with or without root remodeling&#44; or with subcommissural plication annuloplasty with or without STJ remodeling or aortic root remodeling&#44; and with circumferential external or internal annuloplasty with concomitant STJ and root remodeling or as an integral part of reimplantation procedure&#46; The proposed algorithm of decision-making in choosing annuloplasty&#44; root and ascending aorta procedure with regard to root size is presented in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The leaflet repair techniques included prolapse management&#44; raphe excision&#44; enhanced with a patch reconstruction when tissue quality required&#46; The Gore-Tex leaflet stabilization with Gore 7-0 or plication with monofilament 6-0 was added when necessary to correct the remaining prolapse&#46; In all BAV repair cases&#44; the alignment of leaflets was first&#44; followed by the annuloplasty and the final leaflet repair&#46; Strategy of leaflets repair followed classification by Sievers and BAV Consortium&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In BAV type 0 repair&#44; or two-sinus type&#44; both leaflets prolapse has been treated by symmetrical plication to achieve proper effective height&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In BAV type 1 repair&#44; or fused type both symmetric and asymmetric subtype&#44; correction of the reference&#44; non-fused leaflet prolapse&#44; are being addressed first&#46; The correct height of the reference leaflet is determined with the specially designed caliper measuring&#46; The aim is to achieve an effective height greater than 9<span class="elsevierStyleHsp" style=""></span>mm or equal to 50&#37; of the leaflet or root height&#46; This leaflet repair has guided the extent of fused leaflet management&#46; Leaflet shaving is often added to release the leaflet retraction&#46; Root repair and its plication at the leaflet fusion level were performed&#44; as described earlier&#46; In BAV type 1&#44; very asymmetrical type&#44; the linear closure of the major cleft longer than leaflets fusion was carried out&#44; followed by the prolapse plication&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In BAV type 2-unicuspid&#44; a commissurotomy of a minor right-noncoronary commissural fusion is performed converting anatomy to bicuspid type 1 or fused BAV repair&#46; When both major commissural fusions are present resulting in elevated gradient patient are not selected for the repair&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A transesophageal echocardiogram &#40;TEE&#41; is routinely performed three times&#44; before Heart Team&#44; in surgery before the initiation of cardiopulmonary bypass&#44; and at the end of every surgical procedure&#46; The coaptation height is considered acceptable if it was &#8805;4<span class="elsevierStyleHsp" style=""></span>mm after aortic valve repair and effective height above 9<span class="elsevierStyleHsp" style=""></span>mm&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1140">Conflict of interest</span><p id="par0180" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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ISSN: 11340096
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