Bicuspidization with annuloplasty for aortic valve reconstruction in patients with congenital aortic and truncal valve disease
Peter Chiu1, Mariana Chávez1, Kevin Friedman2, Gerald Marx2, Pedro J. del Nido1, Christopher Baird1
1Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts, United States, 2Cardiology, Boston Children's Hospital, Boston, Massachusetts, United States
Objectives: Aortic valve replacement options in infants and children are limited. Aortic valve reconstruction using the bicuspidization technique has been shown to have acceptable results in adults. However, limited results have been published in the pediatric population, and the use of this technique has primarily been limited to patients with unicuspid aortic valves. We report our early outcomes with bicuspidization and aortic annuloplasty in patients with aortic and truncal valve disease.
Methods: A retrospective review of patients with either aortic or truncal valve disease was performed at our institution between 12/2019 and 12/2021, and the analysis was limited to patients who underwent aortic or truncal valve reconstruction to create a bicuspid aortic valve with additional aortic annuloplasty. Small triangular pieces of fixed autologous pericardium were used primarily to reconstruct the commissures and avoid reconstructing the belly of the cusps. Outcomes included survival, reintervention, and recurrence of at least moderate aortic stenosis or regurgitation.
Results: There were 22 patients who underwent bicuspidization with annuloplasty. Median age at surgery was 14 years and weight was 49 kg. Most (68%) patients had regurgitant valves, and 27% had mixed aortic valve disease. There were 4 patients (18%) with truncal valves and 7 (32%) with unicuspid aortic valves. Mean annular diameter by echocardiogram was 24±6 mm; peak gradient for patients with either stenosis or mixed valvular disease was 56±17 mmHg. Autologous pericardium was used in 13 patients for neo-commissural reconstruction. At discharge, 95% (20 of 21) patients had mild or less regurgitation and median peak gradient was 30 (IQR, 23-35) mmHg. There was one in-hospital mortality. Median follow-up time to latest echocardiogram was 7.4 months; 90% of patients had less than moderate regurgitation and 90% had less than moderate stenosis. Use of autologous pericardium and addition of concomitant operations did not affect short-term outcome. One patient, who underwent truncal valve repair at 1 day old, underwent reoperation at 18 months for arch reconstruction and conduit replacement but additionally underwent aortic valvotomy and resection of subaortic membrane.
Conclusions: Aortic valve reconstruction using the bicuspidization technique with annuloplasty has acceptable early results when extended beyond the unicuspid patient population. This technique may be considered in young pediatric patients in whom size or anatomy precludes other conventional options. Importantly, minimizing the use of pericardium to the commissural region leaves the patient predominantly with native cusp. Longer-term follow-up is necessary to evaluate the durability of this technique and further delineate the population of patients who would most likely benefit from this approach.
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