title: Tirone David procedure for bicuspid aortic valve disease: impact of root geometry and valve type on mid-term outcomes.
abstract: OBJECTIVE
  A 180/180° configuration has been reported to increase repair durability after valve-sparing aortic root replacement (V-SARR) for bicuspid aortic valve (BAV) disease. We studied the impact of commissural angular configuration (CAC) and of BAV type on valve performance after V-SARR.
  
  
  METHODS
  A total of 85 BAV patients (68 males, age 44 ± 11 years) underwent Tirone David-V V-SARR between 1997 and 2013. BAV type was documented intraoperatively, and CAC determined from pre- and postoperative computed tomography scans as the angle subtended by the non-fused cusp. Transthoracic echocardiogram was performed at 6 ± 3 days and at 2.9 ± 2.1 years. Functional end-points included freedom from aortic regurgitation (AR) 1+, AR 2+ and freedom from AR progression (0 to 1+, or 1+ to 2+). Tested variables included preoperative CAC (>160 vs <160°) and changes in CAC after V-SARR (Δ > 30° vs Δ < 30°) and Sievers' BAV type (SØ or S1).
  
  
  RESULTS
  CAC in SØ-BAV (n = 26) changed minimally from 164 ± 12 to 171 ± 11° (mean Δ = 7.2 ± 16°, P = 0.044), whereas in S1-BAV (n = 59) CAC changed substantially from 132 ± 19 to 156 ± 18° (mean Δ = 27 ± 21°, P < 0.001). Larger postoperative CAC angles were not linked to better mid-term valve performance, but Sievers' BAV type had a major effect on valve performance: mild AR in S1/i BAV progressed more often (76 vs 32% at 4 years, P = 0.017) and 1+ AR was more frequent (70 vs 36% at 4 years, P = 0.008) compared with SØ-BAV.
  
  
  CONCLUSIONS
  BAV type, including number of raphes, sinuses and commissures (SØ superior to S1) but not commissure geometry within the neoroot alone, appears to be linked to functional outcomes after V-SARR for BAV.
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Stanford University Medical School, Stanford, CA, USA Heart Center Freiburg University, Cardiovascular Surgery, Freiburg, Germany.
authors.forename: Fabian A
authors.initials: FA
authors.lastname: Kari
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Stanford University Medical School, Stanford, CA, USA.
authors.forename: John-Peder E
authors.initials: JP
authors.lastname: Kvitting
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Stanford University Medical School, Stanford, CA, USA.
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Stephens
authors.affiliation: Department of Medicine, Division of Cardiovascular Medicine, Stanford University Medical School, Stanford, CA, USA.
authors.forename: David H
authors.initials: DH
authors.lastname: Liang
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Stanford University Medical School, Stanford, CA, USA.
authors.forename: Denis R
authors.initials: DR
authors.lastname: Merk
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Stanford University Medical School, Stanford, CA, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Fischbein
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Stanford University Medical School, Stanford, CA, USA.
authors.forename: R Scott
authors.initials: RS
authors.lastname: Mitchell
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Stanford University Medical School, Stanford, CA, USA dcm@stanford.edu.
authors.forename: D Craig
authors.initials: DC
authors.lastname: Miller
mesh_terms: D000328:Adult; D001011:Aorta / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001021:Aortic Valve / Q000002:abnormalities* / Q000503:physiopathology / Q000601:surgery; D001022:Aortic Valve Insufficiency / Q000209:etiology; D000082882:Bicuspid Aortic Valve Disease; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D004452:Echocardiography; D005260:Female; D006349:Heart Valve Diseases / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult
keywords: Aortic aneurysm; Aortic valve; Valve-sparing aortic root replacement