title: Root stabilization of the repaired bicuspid aortic valve: subcommissural annuloplasty versus root reimplantation.
abstract: BACKGROUND
  At our institution, type I bicuspid aortic valve (BAV) patients with aortic insufficiency (AI) who are candidates for valve preservation are stratified into two groups by aortic root pathology: nonaneurysmal root undergoing primary cusp repair+subcommissural annuloplasty (repair group) vs aneurysmal root undergoing primary cusp repair+root reimplantation (reimplantation group). We report outcomes of this surgical reconstructive strategy for the repaired type I BAV.
  
  
  METHODS
  A retrospective review was performed of 71 patients with a type I BAV undergoing primary valve repair from 2005 to 2012. The repair group (n=40) underwent annular stabilization by subcommissural annuloplasty, and the reimplantation group (n=31) underwent robust annular stabilization provided by root reimplantation.
  
  
  RESULTS
  Preoperative characteristics and root anatomy were similar, except for increased root dimensions in the reimplantation group (p<0.001). Mortality, stroke, valve reoperation, and pacemaker requirement were zero in both groups. Postoperative peak (19±10 vs 11±5 mm Hg, p<0.001) and mean gradients (10±5 vs 5±3 mm Hg, p<0.001) favored root reimplantation. Freedom from AI greater than 1+ was 100% in both groups. Mean follow-up was 40 months in the reimplantation group and 38 months in the repair group. At 5 years, overall survival was 100% in both groups. Freedom from aortic reoperation and AI exceeding 2+ were similar in both groups. Freedom from AI exceeding 1+ was significantly better in the reimplantation group (92%±6% vs 62%±10%, p=0.03). The 2-year peak (14±6 vs 19±9 mm Hg, p=0.009) and mean (7±4 vs 11±5 mm Hg, p=0.001) gradients favored root reimplantation.
  
  
  CONCLUSIONS
  Root stabilization with the reimplantation technique significantly improves the durability of the repaired type I BAV compared with subcommissural annuloplasty. It also provides improved and sustained valve mobility (transvalvular gradients).
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Prashanth
authors.initials: P
authors.lastname: Vallabhajosyula
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Caroline
authors.initials: C
authors.lastname: Komlo
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Tyler J
authors.initials: TJ
authors.lastname: Wallen
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Nimesh
authors.initials: N
authors.lastname: Desai
authors.affiliation: Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: joseph.bavaria@uphs.upenn.edu.
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Bavaria
mesh_terms: D001021:Aortic Valve / Q000002:abnormalities* / Q000601:surgery; D000082882:Bicuspid Aortic Valve Disease; D006348:Cardiac Surgical Procedures / Q000379:methods; D058385:Cardiac Valve Annuloplasty / Q000379:methods*; D005260:Female; D006330:Heart Defects, Congenital / Q000601:surgery; D006349:Heart Valve Diseases / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome