Bicuspid Ring Annuloplasty and Leaflet Reconstruction After Failed Bicuspid Valve Repair and Aortic Root Remodeling

Abstract

Objectives After bicuspid aortic valve (BAV) repair, annular dilatation can cause recurrent valve dysfunction. This video illustrates a patient undergoing BAV re-repair using ring annuloplasty for progressive annular dilatation and recurrent aortic insufficiency (AI) after a prior BAV reconstruction. Case Video A 36-year-old man had BAV repair and remodeling root replacement four years prior for severe AI and bicuspid root aneurysm. He developed recurrent grade 4 AI, a dilating left ventricle, and a mean systolic gradient of 22 mm Hg. On echocardiography, he had recurrent bileaflet prolapse, a posterior AI jet, and annular dilatation at 27 mm. Surgery was performed through the established remodeling root graft, and major annular remodeling was accomplished with a 21 mm internal bicuspid annuloplasty ring, sutured beneath the leaflets. The Dacron-covered titanium ring had circular base geometry and two outwardly-flaring subcommissural posts, positioned 180° on the circumference. A previous commissural closure was reopened, and after ring annuloplasty, both leaflets were plicated to equivalent effective heights of >8 mm. Good leaflet coaptation was achieved. The patient recovered uneventfully with no complications. After re-repair, AI was reduced to grade 0, and the mean systolic gradient fell to 17 mm Hg. The patient remains asymptomatic late postoperatively, with good echocardiographic parameters and full work activity. Conclusions Adequacy and stability of annuloplasty have been problems after BAV repair. Geometric ring annuloplasty seems effective in remodeling the dilated bicuspid annulus and also could enhance long-term repair stability. Applications such as reoperative root grafts seem especially appealing. Suggested Reading Mazzitelli D, Pfeiffer S, Rankin JS, et al. A regulated trial of bicuspid aortic valve repair supported by geometric ring annuloplasty. Ann Thorac Surg. 2015;99(6):2010-2016 .Mazzitelli D, Nobauer C, Rankin JS, et al. Early results after implantation of a new geometric annuloplasty ring for aortic valve repair. Ann Thorac Surg. 2013;95(1):94-97 .Mazzitelli D, Stamm C, Rankin JS, et al. Hemodynamic outcomes of geometric ring annuloplasty for aortic valve repair: a 4-center pilot trial. J Thorac Cardiovasc Surg. 2014;148(1):168-175 .Mazzitelli D, Nobauer C, Rankin JS, et al. Early results of a novel technique for ring-reinforced aortic valve and root restoration. Eur J Cardiothorac Surg. 2014;45(3):426-430 .Mazzitelli D, Fischlein T, Rankin JS, et al. Geometric ring annuloplasty as an adjunct to aortic valve repair: clinical investigation of the HAART 300 device. Eur J Cardiothorac Surg. 2016;49(3):987-993 .Mazzitelli D, Stamm C, Rankin JS, et al. Leaflet reconstructive techniques for aortic valve repair. Ann Thorac Surg. 2014;98(6):2053-2060 .This video was presented at the 55th Annual Meeting of the Eastern Cardiothoracic Surgery Society in Amelia Island, Florida, on October 19th, 2017. Disclosure Dr Rankin is a consultant for BioStable Science and Engineering in Austin, Texas.