CARDIAC ABNORMALITIES IN YOUNG MALE ELITE HOCKEY PLAYERS PRESELECTED BY THE NATIONAL HOCKEY LEAGUE (NHL) : DETECTION BY SCREENING TRANATHORACIC ECHOCARDIOGRAPHY

Abstract

BACKGROUND: Bicuspid aortic valves (BAV) are commonly classified according to the absence (type 0), presence of 1 (type 1) or 2 (type 2) raphes. Type 1, however, encompasses a wide spectrum of anatomically distinct patterns that are addressed by different repair techniques depending on the behaviour of the raphe, the commissural orientation, the quantity of leaflet tissue and the dimensions of the ventricular-arterial junction (VAJ), among other characteristics. PURPOSE: To establish whether transesophageal echocardiography (TEE) correlates with the surgical findings that modulate the repair approach in BAV patients. METHODS: Pre-operative TEEs of 78 consecutive patients who underwent BAV repair/sparing at our institution between June 2010 and January 2015 were reviewed by one echocardiographer blinded to the surgical findings and procedures. Two surgeons, blinded to TEE data, reviewed the operative videos to determine the anatomical features of the diseased valves and describe the surgical techniques. In our center, type 0 and type 1 BAV with a complete, prolapsing raphe (type 1A) and excess tissue are repaired with free margin plication triangular resection. In symmetrical (commissural orientation 150 ) restrictive type 1 BAV (type 1B), central plication for gap closure and maintenance of bicuspid configuration is usually performed, while asymmetrical (120 ) BAV are considered for tricuspidization with patch, depending on the quantity of tissue. Root-replacement valve-sparing with reimplantation is chosen to stabilize the VAJ when the root is dilated, and subcommissural annuloplasty is used when root dimensions are normal. RESULTS: TEE correctly identified the raphe presence and behaviour (ie. prolapsing vs restrictive) determined at surgical inspection in 84.6% of cases (table). Tricupidization with commissural patch was performed in 4 cases, which had all been appropriately categorized as type 1B with asymmetrical (z120 ) orientation at TEE. Bicuspid configuration was restored in 5 asymmetrical type 1B BAV patients, in whom relatively large VAJ (mean 14.4 1.5 mm/m) and sinuses of Valsalva (18.8 1.3 mm/m) allowed sufficient tissue for bicuspid restoration after aortic root remodelling. CONCLUSION: TEE has the potential to accurately classify BAV according to specific structural and functional patterns that guide the surgical repair approach and that the currently accepted anatomical classifications of BAV do not take into account.