Bicuspid Ring Annuloplasty and Leaflet Reconstruction After Failed Bicuspid Valve Repair and Aortic Root Remodeling

<p><strong>Objectives</strong></p><p>After bicuspid aortic valve (BAV) repair, annular dilatation can cause recurrent valve dysfunction. This video illustrates a patient undergoing BAV re-repair using ring annuloplasty for progressive annular dilatation and recurrent aortic insufficiency (AI) after a prior BAV reconstruction.</p><p><strong>Case Video</strong></p><p>A 36-year-old man had BAV repair and remodeling root replacement four years prior for severe AI and bicuspid root aneurysm. He developed recurrent grade 4 AI, a dilating left ventricle, and a mean systolic gradient of 22 mm Hg. On echocardiography, he had recurrent bileaflet prolapse, a posterior AI jet, and annular dilatation at 27 mm. Surgery was performed through the established remodeling root graft, and major annular remodeling was accomplished with a 21 mm internal bicuspid annuloplasty ring, sutured beneath the leaflets. The Dacron-covered titanium ring had circular base geometry and two outwardly-flaring subcommissural posts, positioned 180° on the circumference. A previous commissural closure was reopened, and after ring annuloplasty, both leaflets were plicated to equivalent effective heights of >8 mm. Good leaflet coaptation was achieved. The patient recovered uneventfully with no complications. After re-repair, AI was reduced to grade 0, and the mean systolic gradient fell to 17 mm Hg. The patient remains asymptomatic late postoperatively, with good echocardiographic parameters and full work activity.</p><p><strong>Conclusions</strong></p><p>Adequacy and stability of annuloplasty have been problems after BAV repair. Geometric ring annuloplasty seems effective in remodeling the dilated bicuspid annulus and also could enhance long-term repair stability. Applications such as reoperative root grafts seem especially appealing.</p><p><strong>Suggested Reading</strong></p><ol><li>Mazzitelli D, Pfeiffer S, Rankin JS, et al. A regulated trial of bicuspid aortic valve repair supported by geometric ring annuloplasty. <em><a href="https://doi.org/10.1016/j.athoracsur.2015.01.050">Ann Thorac Surg. 2015;99(6):2010-2016</a></em>.</li><li>Mazzitelli D, Nobauer C, Rankin JS, et al. Early results after implantation of a new geometric annuloplasty ring for aortic valve repair. <em><a href="https://doi.org/10.1016/j.athoracsur.2012.08.034">Ann Thorac Surg. 2013;95(1):94-97</a></em>.</li><li>Mazzitelli D, Stamm C, Rankin JS, et al. Hemodynamic outcomes of geometric ring annuloplasty for aortic valve repair: a 4-center pilot trial. <em><a href="https://doi.org/10.1016/j.jtcvs.2013.08.031">J Thorac Cardiovasc Surg. 2014;148(1):168-175</a></em>.</li><li>Mazzitelli D, Nobauer C, Rankin JS, et al. Early results of a novel technique for ring-reinforced aortic valve and root restoration. <em><a href="https://doi.org/10.1093/ejcts/ezt407">Eur J Cardiothorac Surg. 2014;45(3):426-430</a></em>.</li><li>Mazzitelli D, Fischlein T, Rankin JS, et al. Geometric ring annuloplasty as an adjunct to aortic valve repair: clinical investigation of the HAART 300 device. <em><a href="https://doi.org/10.1093/ejcts/ezv234">Eur J Cardiothorac Surg. 2016;49(3):987-993</a></em>.</li><li>Mazzitelli D, Stamm C, Rankin JS, et al. Leaflet reconstructive techniques for aortic valve repair. <em><a href="https://doi.org/10.1016/j.athoracsur.2014.06.052">Ann Thorac Surg. 2014;98(6):2053-2060</a></em>.</li></ol><div><p>This video was presented at the 55th Annual Meeting of the <a href="http://www.ectss.org/">Eastern Cardiothoracic Surgery Society</a> in Amelia Island, Florida, on October 19th, 2017.</p><p><strong>Disclosure</strong></p><p>Dr Rankin is a consultant for BioStable Science and Engineering in Austin, Texas.</p></div>

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