Bicuspid aortic valve repair by complete conversion from “raphe'd” (type 1) to “symmetric” (type 0) morphology

Abstract

An anterior cusp with a median raphe and false commissure is the most common bicuspid aortic valve phenotype. The cusp is typically restricted and its annular attachment malpositioned, often resulting in significant aortic regurgitation. A novel valve repair strategy was designed to create a symmetric valve to improve both function and durability. The technique involves converting the valve into a "symmetric" bicuspid valve by resection of the median raphe, with shortening of the anterior cusp's leading edge; resection of the false commissure with complete anterior annular detachment; enlargement, reinforcement, and translocation of the anterior cusp deeper into the left ventricular outflow tract; and valve-sparing aortic root replacement with concomitant annuloplasty. A total of 32 patients with a bicuspid valve, aortic insufficiency, and aortic dilatation have undergone valve repair with root replacement. No operative deaths or strokes occurred, and no permanent pacemakers were required. Thirteen patients underwent complete conversion from "raphe'd" to "symmetric" morphology; the others underwent less complex repairs without translocation. The postoperative transvalvular gradients remained normal. Freedom from grade >1+ aortic regurgitation and valve-related reoperation was 100%. All 13 symmetric conversion patients have continued to have no or trace aortic regurgitation (grade < 1+) at a mean follow-up of 2.9 years (range, 0.4-7). Repair of the common, "raphe'd" bicuspid phenotype by reconfiguration into "symmetric" morphology is both feasible and desirable, regardless of the degree of preoperative aortic regurgitation. This repair strategy appears durable at the mid-term without evolving signs of deterioration or stenosis, offering a potentially superior option over prosthetic root replacement for younger patients.