banner



Home  ›  Can A Bicuspid Aortic Valve Be Repaired

Can A Bicuspid Aortic Valve Be Repaired

Written By Monday, 21 February 2022 Add Comment Edit

Review Article

Concepts and techniques of bicuspid aortic valve repair

Introduction

The bicuspid aortic valve (BAV) is the nigh common cardiac bibelot with an incidence of 0.five–ii% (one,ii). The BAV has ii functional commissures of normal height, making it a bicommissural valve. A third, rudimentary commissure is almost ever nowadays and varies in height. Regurgitation develops at the historic period of ~30 years (3,4), in addition the patients may crave surgery due to aneurysmal dilatation as early as the 3rd decade of life.

Repair techniques for meaning aortic regurgitation (AR) and/or aneurysm related to BAV have evolved over the past 25 years. Initially, a number of reoperations were required at mid-term follow-upwardly despite excellent short-term results subsequently valve repair (5). Over the years dissimilar mechanisms for failure have been identified (half dozen); past specifically addressing them at the fourth dimension of surgery repair immovability could be improved (seven-9). The correction of concomitant aortic dilatation has contributed to improved long-term results (9). We review the current principles and outcomes of BAV repair.

Anatomy and pathophysiology of BAV and aortopathy

There are diverse classifications of BAV, with the classification proposed by Sievers almost widely adopted (10). In this nomenclature the BAV phenotype has been divided into 3 types based on the number of raphes, type 0, blazon 1, and type two (10). Blazon 0 BAV is rare, it has 2 nigh equal cusps and no or merely a minimal raphe with symmetrical commissural orientation (10). While this nomenclature is often used, it is of limited use in the context of BAV repair. Type 1 encompasses all different circumferential orientations of a BAV, and type ii is non a BAV, but a unicuspid aortic valve (11), which has a different pathophysiology, natural history and design of aortic dilatation (12).

The different fusion patterns noted in BAV are correct-left, right-non, and left-not (13). From a surgical standpoint this variability is of limited relevance, since information technology has no influence on the type of procedure which only distinguishes fused vs. non-fused cusps. The existing variability in commissural orientation is less oft appreciated, though it has recently been shown to have a strong effect on repair durability (14). The orientation of the ii functional commissures may vary from 180° (i.e., a symmetric configuration) to 120–140° (an almost tricuspid configuration) (13,14). There is also variability in the caste of fusion, which seems to relate to commissural orientation (14). Symmetric commissures correlate with complete fusion, while the more asymmetric the commissural orientation, the less the fusion. In those instances, the rudimentary commissure may exist of almost normal height. A new classification has recently been proposed which takes these different anatomic patterns into consideration (14).

The mechanism of the evolution of AR has common components in all phenotypes. Prolapse of the fused cusp is almost always present in regurgitant valves (6,15). With bottom degrees of cusp fusion, prolapse may primarily be present in the rudimentary right cusp. In a proportion of cases, the non-fused cusp may also showroom prolapse (6), possibly as a outcome of long-standing regurgitation. Annular dilatation is often observed in regurgitant BAVs and its presence seems to impact repair durability if left uncorrected (6,seven,xvi,17).

Aortic dilatation is oft present in patients with BAVs and can exist a contributing factor to the pathophysiology of AR (3,four). In improver, continued dilatation of the aorta despite BAV repair can result in recurrent AR during follow-upward. BAV is associated with dilatation of the proximal aorta independent of valvular dysfunction in roughly fifty% of patients (iii). Patients with BAV aortopathy have a 6 to 9 fold increased risk of dissection and aortic rupture compared with the full general population (eighteen,19). This appears to exist related to the increased occurrence of dilatation per se rather than the BAV being a specific risk factor (18,19). The BAV associated aortopathy has been classified into dissimilar categories based on the site of dilatation (twenty,21). For practical purposes, information technology is reasonable to distinguish betwixt aortopathy of the root type and the tubular type.

Why repair?

The native aortic valve has excellent hemodynamics, absence of thrombogenicity, resistance to infection, and maintained coronary flow reserve. It seems reasonable to assume that, like to the mitral valve, repair of the native valve should translate into better and long-term clinically relevant outcomes.

Aortic valve replacement (AVR) with mechanical or biologic prostheses has long been the standard of care. Although it is an effective procedure, there are of import long-term drawbacks, particularly in a young population. Mechanical prostheses are associated with reoperation rates in the range of one% per patient year. In addition, survival in non-elderly adults post-obit mechanical AVR is significantly lower than the age- and sexual activity-matched general population (22,23) with a mortality rate of ~i% per year (22-24). Finally, the need for anticoagulation has a stiff impact on quality of life (25) and is associated with risks of major hemorrhagic or thromboembolic events (26). Patients receiving biologic substitutes are at risk of structural valve degeneration, thromboembolism, patient-prosthesis mismatch and reoperation. In addition, excess long-term mortality in non-elderly adults has also been observed afterward biologic AVR (27).

Over the past xx years, BAV repair has get a seemingly ameliorate alternative to AVR with favourable hemodynamics and survival (28-30). The incidence of valve-related complications is low (31-33), with repair failure existence the most frequent complication. The risk of reoperation has been low. With conscientious patient selection and acceptable repair and valve-preserving techniques, durability of >20 years has been documented (34).

History of BAV repair

An initial series of BAV repair was reported by Fraser and coworkers (35), consisting of complimentary margin plication or triangular resection of the prolapsing fused cusp tissue. Subcommissural plication was added (36) to increase leaflet coaptation (35). Early results were promising; intermediate results, still, showed freedom from reoperation of merely 87% at 5 years (5). Repair failure was due to progressive stenosis or recurrent regurgitation (v). Proposed risk factors for failure were triangular resection and dilatation of the ascending aorta (5,37).

Determinants of BAV repair durability

Constructive superlative

In view of these observations we proposed a liberal utilise of aortic replacement in order to stabilize the repair (37). Subsequently we realized that symmetric prolapse or annular dilatation were yet associated with repair failure (6). The presence of prolapse led to the concept of effective height, i.e., the distance between the central free margin and the annluar airplane (38). In normal aortic root beefcake the central margins of the cusps are 9 to 10 mm above the annular airplane (39). A caliper was developed for objective assessment of cusp effective peak as configuration parameter intraoperatively (38). Since then, nosotros systematically aim for an effective height of >8 mm (40). This has led to excellent results with marked improvements in immovability (17,40).

Geometric height

It also became evident that the ability to correct cusp prolapse was related to the corporeality of existing cusp tissue. This was termed "geometric height", i.e., the altitude from the nadir of the cusp to the central gratis margin (41). In BAVs, geometric top of the nonfused cusp was establish to be ≥twenty mm in 95% of individuals with a mean of 24 mm. This cutting-off value was then introduced equally a surrogate parameter for the detection of cusp retraction. Using geometric height for selection of acceptable repair substrates and measurement of constructive pinnacle to guide correction of prolapse, repair has become reproducible and results more anticipated (6,38).

Annular dilatation

The importance of annular dilatation on repair durability was later recognized (six,7,16). Annular dilatation (i.due east., >25–27 mm) is present in the bulk of patients with severe AR. It has been demonstrated that annular dilatation is an independent risk factor for recurrence (6,seven,sixteen). Stabilizing and/or reducing the aortic annulus at the time of surgery has been shown to significantly meliorate the immovability of BAV repair (7,16,17).

Commissural orientation

In parallel, the relevance of commissural orientation became credible (6). The all-time durability (6) and period characteristics across the aortic valve (42) are seen with a symmetric configuration, i.eastward., a commissural angle of 160° to 180°. Standard repair techniques in patients with a commissural angle of <160° led to relevant systolic gradients and poor durability (half dozen). The introduction of systematic modification of commissural orientation was shown to markedly better systolic valve office and repair immovability (viii). Alternatively, liberal root replacement in patients with moderately dilated sinuses has been proposed in order to reposition the commissures at 180° (43).

Patch reconstruction of the cusp

Various studies have shown that utilize of pericardium every bit partial cusp replacement is an independent take chances factor for early failure (6,9,44). Thus, whenever patch reconstruction is required for BAV repair, this should be balanced against durability concerns.

Current concepts of BAV repair

Cusp repair

Cusp repair is invariably required in isolated BAV repair for AR since cusp pathology is a cardinal component. The virtually frequent cusp pathology is prolapse of the fused cusp. There may likewise be prolapse or retraction of the not-fused cusp. Correction of cusp configuration will also oft be necessary in valve-preserving aortic surgery since the reduction of intercommissural distance will frequently event in relevant cusp prolapse (xl).

At the beginning of the procedure, a detailed assessment of cusp morphology, fusion pattern, and circumferential orientation of the commissures has to be performed. Stay sutures are placed in the commissures and kept under tension to provide adequate exposure and mimic a pressurized aortic root (45). Annular dimensions are measured on transesophageal echocardiography and re-assessed past direct intubation using Hegar dilators. An annular diameter of more than 26 mm is considered every bit dilated. Geometric meridian and effective top of the not-fused cusp (reference cusp) are measured (45).

Option of acceptable substrates for repair is important component of the procedure. The cusp tissue should be pliable and without calcification, there must be an adequate amount of cusp tissue. This is best determined by measuring geometric height in the non-fused cusp. A geometric pinnacle of ≥twenty mm volition be sufficient for repair (41). In gild to place prolapse reproducibly, intraoperative measurement of effective height with a caliper has shown to improve cess of cusp configuration (38). In BAVs the level of aortic insertion of the 2 components of the valve varies. Effective height can only be reliably measured in the non-fused cusp, and this is so used equally reference for the fused cusp. An effective superlative of nine–10 mm of the non-fused cusp has consistently led to stable results unless other complicating pathology was nowadays. Induced prolapse due to reduction of intercommissural distance is a frequent finding if associated aneurysm is treated by aortic replacement involving the sinotubular junction. In such cases, it is important to perform cusp assessment after aortic replacement, i.e., when intercommissural altitude has been reduced.

Central plication of the cusp free margin has proven to be the most reproducible technique for correcting cusp prolapse (35,46,47). Sutures placed in the pericommissural areas of the cusp can hands tear because this portion of the root is under highest stress (48,49). The plication is primarily washed at the level of the gratis margin; depending on the extent of prolapse it may be extended into the belly of the cusp to limit postoperative billowing. Prolapse of the fused cusp is substantially always present, and so the plication volition be practical to this cusp regularly. If there is additional prolapse of the non-fused cusp, both cusps can be corrected without impacting the results negatively.

Non infrequently, dense fibrosis or limited calcification may be present in the raphe. If central plication is hard because of these tissue changes, a triangular resection may exist performed (45). Nosotros use fine interrupted polyethylene sutures (5-0) to re-approximate cusp tissue and avert a continuous suture in social club to minimize the chance of cusp retraction. If cusp calcification extends beyond the raphe, BAV repair should exist reconsidered considering of a high probability of limited durability.

Commissural orientation is an of import part of BAV beefcake and must be taken into consideration when choosing the repair strategy. A commissural angle of 160–180° can be left equally such (Effigy ane). If the bending is 140–160°, its modification has shown to decrease postoperative systolic gradients and improve mobility of the fused cusp and durability (8,9). This tin be achieved past plication of the fused sinus from he base and to the level of the sinotubular junction (eight). Alternatively it may be performed through root replacement and change of the configuration within a graft for reimplantation (51) or besides through appropriate configuration of the graft tongues in root remodeling (ix). If the commissural angle is <140°, the valve is probably all-time treated in analogy to tricuspid aortic valves (46). In this setting, prolapse of the private cusps is treated separately.

Concomitant aortic replacement

Patients undergoing cardiac surgery with an ascending aortic diameter of >45 mm can be managed with concomitant repair of ascending aorta/root for prognostic reasons (52). Withal, the recommendation does not differentiate between valve repair and replacement. Indeed, if the valve is repaired, concomitant aortic replacement (in mildly dilated aortas) has been associated with improved durability (6,51).

In deciding for or against root replacement nosotros take into consideration the increased complication of the process against the improved durability of repair after root replacement. Whenever root dimensions are enlarged (≥42 mm), ascending aorta and root are replaced if repair is performed in our routine. The graft size must accommodate the size of the patient besides as downstream aorta. In root remodeling the commissural orientation of the graft is placed at 180° (9). Two symmetric tongues are created to accommodate both fused and nonfused sinus (45). Information technology is important to ensure that the commissures are placed high to avoid commissural brake. Therefore, nosotros propose suturing the graft from the nadir to the commissures, extending the graft incision as dictated past the patient's anatomy. Recently some data have been published using reimplantation for the same purpose. Early results have been comparable (53,54), while late results are not yet available.

If root dimensions are <43 mm (depending on age and torso surface expanse of the patient), we refrain from replacing the root. Mid- to long-term observations have shown stability of the aortic root with such an approach (seven,eight,29).

Aortic annuloplasty

Annular dilatation is almost always present in regurgitant BAVs and has been associated with poor durability (6). Our definition of annular dilatation currently is a diameter ≥26–27 mm. Nosotros and others (40,47) had used subcommissural plication sutures previously. It was constitute that they did not stabilize the annulus sufficiently (16) and were actually associated with repair failure (6).

In choosing an annuloplasty technique the anatomy of the aortic annulus must exist considered. The structure to exist stabilized is not the true anatomic annulus, best represented past the crown-shaped gristly construction of the cusp insertion lines (55). It is rather the caudal edge of the root, which connects the cusp nadirs along a horizontal plane (also known as the basal band). This should exist considered as the functional annulus because it determines valve geometry (55). This basal airplane tin differ from the aortoventricular junction, with the aortoventricular junction lying more than cranial than the virtual basal ring (55). In normal, tricuspid aortic valves, this difference is more often than not limited (56,57) while in BAVs a more pronounced distance (reaching up to 10–fifteen mm in summit) may be encountered, particularly in the right coronary sinus (14,56,57). This can limit the extent to which an external ring can exist brought down to the level of the basal plane. Therefore we favour addressing annular dilatation by performing a suture annuloplasty using expanded polytetrafluorethylene (PTFE; CV-0, Gore-Tex CV-0; WL Gore and Associates, Munich, Germany). This material has proven to be skilful for this purpose (7). The suture is placed circumferentially along the basal band and tied around a Hegar dilator at the desired annular diameter. We commonly take a 25 mm Hegar for larger patients (>2 m2 body area) and 23 mm for smaller individuals.

The annuloplasty can be used in isolated BAV repair or as an offshoot to valve-sparing root remodeling. Some early complications with initial use of different suture materials (7) could be largely eliminated with use of the PTFE suture (Gore-Tex CV-0; WL Gore and Associates, Munich, Germany). Regardless of whatsoever annuloplasty technique, conscientious attending to the specific anatomy of the left coronary artery is critical to avoid interference with the left main or the circumflex coronary. Equally yet, the addition of an annuloplasty to remodeling in BAV has resulted in a higher proportion of completely competent aortic valves (9,58); all the same, an improvement in freedom from reoperation has not yet been demonstrated (9).

When non to repair?

Limitations of repair are related to the morphology of the cusps and commissures. Currently, the need for cusp augmentation or partial replacement of cusps using patch material is associated with poor durability. This is related to early degeneration of autologous pericardium currently used for cusp replacement. We have as well observed progressive calcification of the whole valve in patients who required fractional cusp replacement after calcium excision. Thus, cusp retraction (geometric tiptop <20 mm) or calcification of the raphe that cannot be treated by excision and direct approximation of cusp tissue are currently amend treated by replacement. The presence of active endocarditis falls into the aforementioned category according to electric current knowledge.

Unfavorable commissural orientation will increase the complication of the repair and decrease the immovability (fourteen). Although asymmetric or very asymmetric BAVs tin can be repaired, they represent a college technical challenge to the surgeon. Closure of fenestrations in BAVs and the creation of a tricuspid design by a commissural reconstruction are associated with decreased durability in our experience. In such scenarios the threshold for replacement should be low in light of shorter expected durability.

Conclusions

Aortic valve repair has evolved over the past 2 decades. The techniques have become standardized and reproducible and offering a tailored and predictable arroyo to the bulk of patients with non-calcified BAVs (59). Currently, BAV repair remains underused in the majority of centers, including high-volume aortic centers. Improved understanding of the mechanisms of regurgitation, predictors of repair durability, and surgical techniques volition hopefully translate into wider adoption of this arroyo, like to mitral valve repair. A new classification system that includes the anatomic features of the BAV in the context of surgical repair has been proposed (14). This will further meliorate the clarity and comparability of different surgical approaches in the future.

Acknowledgments

Funding: None.

Provenance and Peer Review: This article was commissioned past the Guest Editors (Filip Casselman and Johan van der Merwe) for the serial "Aortic and Mitral Valve Innovative Surgery" published in Journal of Visualized Surgery. The article has undergone external peer review.

Conflicts of Interest: All authors take completed the ICMJE compatible disclosure form (bachelor at http://dx.doi.org/10.21037/jovs.2019.09.06). The series "Aortic and Mitral Valve Innovative Surgery" was commissioned by the editorial office without whatever funding or sponsorship. The authors accept no other conflicts of interest to declare.

Ethical Argument: The authors are accountable for all aspects of the piece of work in ensuring that questions related to the accurateness or integrity of whatsoever part of the work are accordingly investigated and resolved.

Open Access Statement: This is an Open up Admission article distributed in accordance with the Creative Eatables Attribution-NonCommercial-NoDerivs iv.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the commodity with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). Encounter: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

  1. Ward C. Clinical significance of the bicuspid aortic valve. Eye 2000;83:81-5. [Crossref] [PubMed]
  2. Siu SC, Silversides CK. Bicuspid aortic valve illness. J Am Coll Cardiol 2010;55:2789-800. [Crossref] [PubMed]
  3. Masri A, Kalahasti V, Alkharabsheh S, et al. Characteristics and long-term outcomes of contemporary patients with bicuspid aortic valves. J Thorac Cardiovasc Surg 2016;151:1650-nine.e1651.
  4. Michelena HI, Desjardins VA, Avierinos JF, et al. Natural history of asymptomatic patients with unremarkably operation or minimally dysfunctional bicuspid aortic valve in the community. Apportionment 2008;117:2776-84. [Crossref] [PubMed]
  5. Casselman FP, Gillinov AM, Akhrass R, et al. Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet. Eur J Cardiothorac Surg 1999;15:302-8. [Crossref] [PubMed]
  6. Aicher D, Kunihara T, Abou Issa O, et al. Valve configuration determines long-term results subsequently repair of the bicuspid aortic valve. Circulation 2011;123:178-85. [Crossref] [PubMed]
  7. Schneider U, Hofmann C, Aicher D, et al. Suture annuloplasty significantly improves the immovability of bicuspid aortic valve repair. Ann Thorac Surg 2017;103:504-10. [Crossref] [PubMed]
  8. Schneider U, Schmied Due west, Aicher D, et al. Sinus plication to better valve configuration in bicuspid aortic valve repair-early results. Ann Thorac Surg 2017;103:580-5. [Crossref] [PubMed]
  9. Schneider U, Feldner SK, Hofmann C, et al. Two decades of experience with root remodeling and valve repair for bicuspid aortic valves. J Thorac Cardiovasc Surg 2017;153:S65-71. [Crossref] [PubMed]
  10. Sievers HH, Schmidtke C. A classification organization for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg 2007;133:1226-33. [Crossref] [PubMed]
  11. Anderson RH. Understanding the structure of the unicuspid and unicommissural aortic valve. J Heart Valve Dis 2003;12:670-3. [PubMed]
  12. Noly PE, Basmadjian Fifty, Bouhout I, et al. New insights into unicuspid aortic valve disease in adults: Not but a subtype of bicuspid aortic valves. Can J Cardiol 2016;32:110-half dozen. [Crossref] [PubMed]
  13. Sabet HY, Edwards WD, Tazelaar Hard disk, et al. Congenitally bicuspid aortic valves: A surgical pathology study of 542 cases (1991 through 1996) and a literature review of ii,715 additional cases. Mayo Clin Proc 1999;74:14-26. [Crossref] [PubMed]
  14. de Kerchove L, Mastrobuoni S, Froede 50, et al. Variability of repairable bicuspid aortic valve phenotypes: Towards an anatomical and repair-oriented classification. Eur J Cardiothorac Surg 2019; [Epub ahead of impress]. [Crossref] [PubMed]
  15. Ridley CH, Vallabhajosyula P, Bavaria JE, et al. The sievers classification of the bicuspid aortic valve for the perioperative echocardiographer: The importance of valve phenotype for aortic valve repair in the era of the functional aortic annulus. J Cardiothorac Vasc Anesth 2016;30:1142-51. [Crossref] [PubMed]
  16. Navarra E, El Khoury K, Glineur D, et al. Effect of annulus dimension and annuloplasty on bicuspid aortic valve repair. Eur J Cardiothorac Surg 2013;44:316-22; give-and-take 322-3. [Crossref] [PubMed]
  17. Lansac East, Di Centa I, Sleilaty Thou, et al. Remodeling root repair with an external aortic ring annuloplasty. J Thorac Cardiovasc Surg 2017;153:1033-42. [Crossref] [PubMed]
  18. Tzemos N, Therrien J, Yip J, et al. Outcomes in adults with bicuspid aortic valves. JAMA 2008;300:1317-25. [Crossref] [PubMed]
  19. Michelena Howdy, Khanna AD, Mahoney D, et al. Incidence of aortic complications in patients with bicuspid aortic valves. JAMA 2011;306:1104-12. [Crossref] [PubMed]
  20. Fazel SS, Mallidi Hour, Lee RS, et al. The aortopathy of bicuspid aortic valve disease has distinctive patterns and commonly involves the transverse aortic curvation. J Thorac Cardiovasc Surg 2008;135:901-7, 907.e901-2.
  21. Della Corte A, Bancone C, Quarto C, et al. Predictors of ascending aortic dilatation with bicuspid aortic valve: A wide spectrum of disease expression. Eur J Cardiothorac Surg 2007;31:397-404; discussion 404-5. [Crossref] [PubMed]
  22. Bouhout I, Stevens LM, Mazine A, et al. Long-term outcomes after elective isolated mechanical aortic valve replacement in young adults. J Thorac Cardiovasc Surg 2014;148:1341-1346.e1. [Crossref] [PubMed]
  23. Kvidal P, Bergstrom R, Horte LG, et al. Observed and relative survival subsequently aortic valve replacement. J Am Coll Cardiol 2000;35:747-56. [Crossref] [PubMed]
  24. Goldstone AB, Chiu P, Baiocchi Chiliad, et al. Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement. N Engl J Med 2017;377:1847-57. [Crossref] [PubMed]
  25. Aicher D, Holz A, Feldner S, et al. Quality of life subsequently aortic valve surgery: Replacement versus reconstruction. J Thorac Cardiovasc Surg 2011;142:e19-24. [Crossref] [PubMed]
  26. Puskas J, Gerdisch M, Nichols D, et al. Reduced anticoagulation after mechanical aortic valve replacement: Interim results from the prospective randomized on-x valve anticoagulation clinical trial randomized food and drug administration investigational device exemption trial. J Thorac Cardiovasc Surg 2014;147:1202-x; discussion 1210-1. [Crossref] [PubMed]
  27. Forcillo J, El Hamamsy I, Stevens LM, et al. The perimount valve in the aortic position: Twenty-year experience with patients under 60 years quondam. Ann Thorac Surg 2014;97:1526-32. [Crossref] [PubMed]
  28. Collins JD, Semaan E, Barker A, et al. Comparing of hemodynamics subsequently aortic root replacement using valve-sparing or bioprosthetic valved conduit. Ann Thorac Surg 2015;100:1556-62. [Crossref] [PubMed]
  29. Ashikhmina East, Sundt TM 3rd, Dearani JA, et al. Repair of the bicuspid aortic valve: A viable alternative to replacement with a bioprosthesis. J Thorac Cardiovasc Surg 2010;139:1395-401. [Crossref] [PubMed]
  30. de Meester C, Pasquet A, Gerber BL, et al. Valve repair improves the consequence of surgery for chronic severe aortic regurgitation: A propensity score assay. J Thorac Cardiovasc Surg 2014;148:1913-20. [Crossref] [PubMed]
  31. Aicher D, Chips R, Rodionycheva S, et al. Aortic valve repair leads to a depression incidence of valve-related complications. Eur J Cardiothorac Surg 2010;37:127-32. [Crossref] [PubMed]
  32. Price J, De Kerchove L, Glineur D, et al. Chance of valve-related events afterwards aortic valve repair. Ann Thorac Surg 2013;95:606-12; give-and-take 613. [Crossref] [PubMed]
  33. Arabkhani B, Mookhoek A, Di Centa I, et al. Reported issue after valve-sparing aortic root replacement for aortic root aneurysm: A systematic review and meta-analysis. Ann Thorac Surg 2015;100:1126-31. [Crossref] [PubMed]
  34. David TE, Feindel CM, David CM, et al. A quarter of a century of experience with aortic valve-sparing operations. J Thorac Cardiovasc Surg 2014;148:872-9; discussion 879-80. [Crossref] [PubMed]
  35. Fraser CD Jr, Wang Northward, Mee RB, et al. Repair of insufficient bicuspid aortic valves. Ann Thorac Surg 1994;58:386-90. [Crossref] [PubMed]
  36. Cabrol C, Cabrol A, Guiraudon Grand, et al. Treatment of aortic insufficiency by means of aortic annuloplasty. Arch Mal Coeur Vaiss 1966;59:1305-12. [PubMed]
  37. Schäfers HJ, Langer F, Aicher D, et al. Remodeling of the aortic root and reconstruction of the bicuspid aortic valve. Ann Thorac Surg 2000;seventy:542-6. [Crossref] [PubMed]
  38. Schäfers HJ, Bierbach B, Aicher D. A new arroyo to the assessment of aortic cusp geometry. J Thorac Cardiovasc Surg 2006;132:436-eight. [Crossref] [PubMed]
  39. Bierbach BO, Aicher D, Issa OA, et al. Aortic root and cusp configuration determine aortic valve function. Eur J Cardiothorac Surg 2010;38:400-half dozen. [Crossref] [PubMed]
  40. Schäfers HJ, Aicher D, Langer F, et al. Preservation of the bicuspid aortic valve. Ann Thorac Surg 2007;83:S740-5; discussion S785-ninety.
  41. Schäfers HJ, Schmied West, Marom G, et al. Cusp top in aortic valves. J Thorac Cardiovasc Surg 2013;146:269-74. [Crossref] [PubMed]
  42. Kari FA, Liang DH, Kvitting JP, et al. Tirone david valve-sparing aortic root replacement and cusp repair for bicuspid aortic valve disease. J Thorac Cardiovasc Surg 2013;145:S35-40.e31-ii.
  43. de Kerchove L, Boodhwani Thousand, Glineur D, et al. Valve sparing-root replacement with the reimplantation technique to increase the immovability of bicuspid aortic valve repair. J Thorac Cardiovasc Surg 2011;142:1430-8. [Crossref] [PubMed]
  44. Mosala Nezhad Z, de Kerchove L, Hechadi J, et al. Aortic valve repair with patch in not-rheumatic disease: Indication, techniques and durabilitydagger. Eur J Cardiothorac Surg 2014;46:997-1005; give-and-take 1005. [Crossref] [PubMed]
  45. Schneider U, Schäfers HJ. Repair of the bicuspid aortic valve. Oper Techn in Thor and Cardiovasc Surg 2017;22:91-109. [Crossref]
  46. Langer F, Graeter T, Nikoloudakis North, et al. Valve-preserving aortic replacement: Does the additional repair of leaflet prolapse adversely affect the results? J Thorac Cardiovasc Surg 2001;122:270-7. [Crossref] [PubMed]
  47. El Khoury G, Vanoverschelde JL, Glineur D, et al. Repair of bicuspid aortic valves in patients with aortic regurgitation. Circulation 2006;114:I610-half dozen. [Crossref] [PubMed]
  48. Marom G, Haj-Ali R, Raanani Due east, et al. A fluid-structure interaction model of the aortic valve with coaptation and compliant aortic root. Med Biol Eng Comput 2012;50:173-82. [Crossref] [PubMed]
  49. Grande-Allen KJ, Cochran RP, Reinhall PG, et al. Re-cosmos of sinuses is of import for sparing the aortic valve: A finite element study. J Thorac Cardiovasc Surg 2000;119:753-63. [Crossref] [PubMed]
  50. Schneider U, Karliova I, Giebels C, et al. Concepts and techniques of bicuspid aortic valve repair. Asvide 2020;7:028. Available online: http://world wide web.asvide.com/watch/33049
  51. Mastrobuoni S, de Kerchove L, Navarra E, et al. Long-term experience with valve-sparing reimplantation technique for the treatment of aortic aneurysm and aortic regurgitation. J Thorac Cardiovasc Surg 2019;158:14-23. [Crossref] [PubMed]
  52. Borger MA, Fedak PWM, Stephens EH, et al. The american association for thoracic surgery consensus guidelines on bicuspid aortic valve-related aortopathy: Full online-simply version. J Thorac Cardiovasc Surg 2018;156:e41-74. [Crossref] [PubMed]
  53. Kayatta MO, Leshnower BG, McPherson Fifty, et al. Valve-sparing root replacement provides excellent midterm outcomes for bicuspid valve aortopathy. Ann Thorac Surg 2019;107:499-504. [Crossref] [PubMed]
  54. Lenoir M, Maesen B, Stevens LM, et al. Reimplantation versus remodelling with ring annuloplasty: Comparison of mid-term outcomes after valve-sparing aortic root replacement. Eur J Cardiothorac Surg 2018;54:48-54. [Crossref] [PubMed]
  55. Anderson RH. Clinical anatomy of the aortic root. Heart 2000;84:670-3. [Crossref] [PubMed]
  56. de Kerchove 50, Jashari R, Boodhwani M, et al. Surgical anatomy of the aortic root: Implication for valve-sparing reimplantation and aortic valve annuloplasty. J Thorac Cardiovasc Surg 2015;149:425-33. [Crossref] [PubMed]
  57. Khelil N, Sleilaty One thousand, Palladino 1000, et al. Surgical anatomy of the aortic annulus: Landmarks for external annuloplasty in aortic valve repair. Ann Thorac Surg 2015;99:1220-6. [Crossref] [PubMed]
  58. Lansac E, Di Centa I, Raoux F, et al. An expansible aortic ring for a physiological arroyo to bourgeois aortic valve surgery. J Thorac Cardiovasc Surg 2009;138:718-24. [Crossref] [PubMed]
  59. Miyahara South, Schneider U, Morgenthaler L, et al. (Virtually) All Nonstenotic Bicuspid Aortic Valves Should Be Preserved or Repaired. Semin Thorac Cardiovasc Surg 2019. [Epub alee of print].

doi: 10.21037/jovs.2019.09.06
Cite this article every bit: Schneider U, Karliova I, Giebels C, Ehrlich T, Schäfers HJ. Concepts and techniques of bicuspid aortic valve repair. J Vis Surg 2020;6:three.

Source: https://jovs.amegroups.com/article/view/30234/html

Posted by: bridgesdivichimahme.blogspot.com

0 Response to "Can A Bicuspid Aortic Valve Be Repaired"

Post a Comment

Subscribe to: Post Comments (Atom)

Iklan Atas Artikel

Iklan Tengah Artikel 1

Iklan Tengah Artikel 2

Iklan Bawah Artikel