title: Effect of annulus dimension and annuloplasty on bicuspid aortic valve repair.
abstract: OBJECTIVE
  We have recently shown that valve sparing reimplantation (VSR) improves the durability of bicuspid aortic valve repair in comparison with subcommissural annuloplasty. The aim of this study was to assess the degree of annular reduction provided by these techniques and to correlate these findings with repair durability.
  
  
  METHODS
  From 1995 to 2010, 161 patients underwent bicuspid valve repair. We included only patients with subcommissural annuloplasty or reimplantation having intraoperative pre- and post-repair transoesophageal echocardiography images. Pre- and post-repair ventriculo-aortic junction (VAJ) diameters were measured on long axis views. Inclusion criteria were met by 53 patients with subcommissual annuloplasty and 65 with reimplantation. Median follow-up was 53 months in the subcommissual annuloplasty group and 42 months in the reimplantation group. Follow-up completeness was 100% in subcommissural annuloplasty and 94% in reimplantation.
  
  
  RESULTS
  There was no operative or late mortality. Mean preoperative VAJ was similar in both groups (reimplantation: 28 ± 3 mm vs subcommissural annuloplasty: 28 ± 3, P = 0.16). Preoperative VAJ was larger in patients <40 years and with aortic regurgitation (AR) ≥ 3+ (P < 0.01). Mean postoperative VAJ was smaller in reimplantation compared with subcommissural annuloplasty (21 ± 2 mm vs 24 ± 3 mm, P < 0.01). In univariate analyses, subcommissural annuloplasty, preoperative VAJ ≥ 30 mm, postoperative VAJ ≥ 25 mm and cusp repair with patch were predictive of recurrent AR > 1+. In the subcommissural annuloplasty group, VAJ≥ 30 mm preoperatively and ≥ 25 mm postoperatively were associated with decreased 6 years freedom from recurrent AR>1+ (<30 mm: 74% vs ≥ 30 mm: 39%, P = 0.01; <25 mm: 80% vs ≥ 25 mm 31%, P = 0.02) In the reimplantation group, VAJ dimension had no effect on recurrent AR >1+ (P = 0.93).
  
  
  CONCLUSIONS
  In bicuspid aortic valve repair, the circumferential annuloplasty of VSR offers greater reduction of VAJ compared with the non-circumferential annuloplasty provided by the subcommissural annuloplasty. The degree and extent of VAJ reduction in reimplantation seem to be factors among others that positively influence repair durability particularly in patients with a large VAJ (≥ 30 mm).
authors.affiliation: Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
authors.forename: Emiliano
authors.initials: E
authors.lastname: Navarra
authors.forename: Gebrine
authors.initials: G
authors.lastname: El Khoury
authors.forename: David
authors.initials: D
authors.lastname: Glineur
authors.forename: Munir
authors.initials: M
authors.lastname: Boodhwani
authors.forename: Michel
authors.initials: M
authors.lastname: Van Dyck
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Vanoverschelde
authors.forename: Philippe
authors.initials: P
authors.lastname: Noirhomme
authors.forename: Laurent
authors.initials: L
authors.lastname: de Kerchove
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D001021:Aortic Valve / Q000002:abnormalities* / Q000473:pathology* / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000601:surgery; D000082882:Bicuspid Aortic Valve Disease; D058385:Cardiac Valve Annuloplasty / Q000379:methods*; D005260:Female; D006349:Heart Valve Diseases / Q000473:pathology* / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D016896:Treatment Outcome
keywords: Aortic root aneurysm; Aortic valve repair; Bicuspid aortic valve; Valve regurgitation; Valve sparing surgery