Invited commentary

Abstract

This paper from Frankfurt belongs to the sporadic number of papers that since the early 1960s have reported the results of aortic valve cusp extension in small groups of patients. The problems of aortic cusp extension are the need for a reliable surgical technique and the choice of the right material [1Duran C.M.G. Gometza B. Kumar N. et al.From cusp extension to valve replacement with stentless pericardium.Ann Thorac Surg. 1995; 60: S428-S432Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 2Duran C.M.G. Gallo R. Kumar N. Aortic replacement with autologous pericardium. Surgical technique.J Cardiac Surg. 1995; 10: 1-9Crossref PubMed Scopus (38) Google Scholar, 3Duran C.M.G. Gometza B. Kumar N. et al.Aortic valve replacement with freehand autologous pericardium.J Thorac Cardiovasc Surg. 1995; 110: 511-516Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar]. The authors have chosen extension of the fused leaflet of bicuspid valves with glutaraldehyde-treated autologous pericardium. Our early experience with single cusp extension was abandoned because of the practical impossibility of achieving a good geometric result. Although immediate competence was usually obtained, this was due to significant bending of the redundant new cusp, which was always larger than the other two cusps. We favor a trileaflet extension, where equal leaflets with similar coaptation areas are easier to achieve. In bicuspid cases, after excision of all valvular tissue, three equidistant commissures were constructed. This choice was also based on several studies showing the geometric superiority of a trileaflet over a bicuspid valve. However, the excellent clinical results of the Frankfurt group might disprove this assumption. The authors’ choice of autologous pericardium immersed for a few minutes in glutaraldehyde seems to me right [4Duran C.M.G. Gometza B. Shaid M. Al Halees Z. Treated bovine and autologous pericardium for aortic valve reconstruction.Ann Thorac Surg. 1998; 66: S166-S169Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar]. Synthetic materials rapidly calcify and fresh autologous pericardium undergoes fibrotic retraction. Glutaraldehyde-treated xenopericardium and autologous pericardium have been preferentially used. In our series of 92 consecutive young patients (mean, 30 years) glutaraldehyde-treated pericardium of bovine (n = 27) or autologous (n = 65) origin was used. Hospital mortality was 2%. At a maximum 14 years follow-up (mean, 7.5; range, 7 to 14), no thromboembolic events had been detected in spite of absence of anticoagulation. Overall survival at 14 years was 85 ± 4%. Freedom from structural deterioration was 58 ± 9% for the bovine and 76 ± 10% for the autologous pericardium. Freedom from reoperation was 47 ± 8% for bovine and 59 ± 9% for the autologous valves [5Al Halees Z. Shahid M. Al Sanei A. Duran C. Up to 14 years follow-up of aortic valve reconstruction with pericardium. 2004Google Scholar]. While the cause of failure of the bovine tissue was calcification, the autologous had failed because of tears or infection. Histology showed an acellular collagen matrix that had an epithelial layer in the autologous and was absent in the bovine specimens. In conclusion, although aortic valve cusp extension with glutaraldehyde-treated autologous pericardium is feasible, nonthrombogenic, and hemodynamically excellent, it is technically difficult and consequently unlikely to become widely accepted. Although its durability beyond 10 years is questionable, it offers a valid alternative in young patients, where anticoagulation with a mechanical valve and reoperation with a bioprosthesis are serious problems. Whether bicuspid valves should undergo single or triple cusp extensions must wait for a longer follow-up. In any case, the authors should be congratulated for their original contribution and for maintaining alive the flame of aortic cusp extension. Pericardial Patch Augmentation for Reconstruction of Incompetent Bicuspid Aortic ValvesThe Annals of Thoracic SurgeryVol. 80Issue 1PreviewReoperation rates after repair of bicuspid aortic valves are higher than for mitral valve reconstruction. Secondary changes and small coaptation surface render repair unreliable. Satisfactory results have been reported for patch augmentation for tricuspid aortic valves. We have applied this technique for the repair of bicuspid aortic valves. Full-Text PDF