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Aortic Valve Repair of a Stenotic Unicuspid Aortic Valve in Young Patients
Accepted Manuscript Aortic Valve Repair of a Stenotic Unicuspid Aortic Valve in Young Patients Adrian Kolesar, MD, PhD, MPH, Tomas Toporcer, MD, PhD, Milan Bajmoczi, MD, PhD, Jan Luczy, MD, PhD, MPH, Peter Candik, MD, PhD, MPH, Frantisek Sabol, MD, PhD, MPH, MBA PII:
S0003-4975(18)30051-1
DOI:
10.1016/j.athoracsur.2017.12.031
Reference:
ATS 31280
To appear in:
The Annals of Thoracic Surgery
Received Date: 13 July 2017 Revised Date:
2 November 2017
Accepted Date: 21 December 2017
Please cite this article as: Kolesar A, Toporcer T, Bajmoczi M, Luczy J, Candik P, Sabol F, Aortic Valve Repair of a Stenotic Unicuspid Aortic Valve in Young Patients, The Annals of Thoracic Surgery (2018), doi: 10.1016/j.athoracsur.2017.12.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Aortic Valve Repair of a Stenotic Unicuspid Aortic Valve in Young Patients Running title: Aortic Valve Repair
Adrian Kolesar, MD, PhD, MPH1, Tomas Toporcer, MD, PhD1, Milan Bajmoczi, MD, PhD2,
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Jan Luczy, MD, PhD, MPH1, Peter Candik, MD, PhD, MPH3, Frantisek Sabol, MD, PhD, MPH, MBA1
Clinic of Cardiac Surgery, Eastern Slovak Institute for Cardiovascular Diseases, Ondavska,
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1
Slovakia
Fairbanks Memorial Hospital - Harry & Sally Porter Heart & Vascular Center, Fairbanks,
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2
Alaska 3
Department of Anesthesiology and Intensive Medicine, Eastern Slovak Institute for
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Cardiovascular Diseases, Kosice, Slovakia
Keywords
Aortic Valve
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Aortic Valve Repair, Aortic Valve Congenital abnormalities, Bicuspidization, Unicuspid
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Word count
Corresponding author: Tomas Toporcer, MD, PhD Ondavska 8, Kosice, 04011, Slovakia Email: [email protected]
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ACCEPTED MANUSCRIPT Abstract Background. The unicuspid aortic valve (UAV) is a well-described pediatric congenital abnormality, with incidence of 0.02% in the general population. Bicuspidization has been described as a potential surgical option to repair this defect.
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Methods. Seventeen symptomatic young patients with a unicuspid valve combined with either valve insufficiency or valve stenosis underwent aortic valve bicuspidization procedure using either an equine pericardium. In addition to bicuspidization, eight patients underwent aortic
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ring implantation and five patients underwent supracoronary replacement of the aorta.
Results. Our results show safety of the bicuspidization procedure. There were no mortalities
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during our average follow-up period of 26 months. Freedom from reoperation for any valverelated reason was 100% during this follow-up period. We observed a statistically significant increase in the aortic valve area from 0.8±0.1cm2 to 2.8±0.7cm2 (p<0.01), a statistically significant decrease in the mean systolic pressure gradient from 36±13.3mmHg to 9±4mmHg
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(p<0.001), a statistically significant decrease in aortic insufficiency grade from 2.1±1.0 to 0.6±0.7 (p<0.01) pre- and post-bicuspidization, respectively, and a statistically significant decrease in the left ventricle end-diastolic diameter (mm) from 49.88±5.11 to 40.46±7.20
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(p<0.0005) as well as a statistically significant increase of left ventricle ejection fraction from 56±8.20 to 64±7.83 at the time of follow-up.
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Conclusions. Based on our study, bicuspidization is an attractive surgical option to repair UAV, particularly in young patients who do not want to be subjected to long-term anticoagulation therapy or who refuse a more traditional surgical approach, such as Ross procedure, for reasons described previously.
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ACCEPTED MANUSCRIPT Aortic stenosis (AS) was first described in 1672 when Rayger identified calcified aortic valve cusps at autopsy [1]. The most common cause of AS is a degenerative calcification of the aortic valve. Calcified bicuspid aortic valves represent the most common form of congenital AS [2]. The second most common form of congenital AS is seen with unicuspid
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aortic valve anatomy, which is present in 4-6% of patients undergoing surgery for AS [3, 4, 5].
Unicuspid aortic valve (UAV) is a well-described pediatric congenital abnormality. It
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was first described by Edwards in 1958 [6, 7]. On the other hand, bicuspid aortic valve (BAV) was originally described by John Hunter (the specimens are still available at the Hunterian
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museum at the Royal College of Surgeons in London). Hunter´s son-in-law then published drawings of Hunter´s BAV specimens, but showed no UAV [8]. During embryonic development, the aortic valve is formed from three tubercles, abnormal fusion of which can result in either a unicuspid or a bicuspid aortic valve [9]. UAV incidence has been estimated
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to be only 0.02% in general population [10, 11], but it remains a frequent reason for aortic valve operation in teenagers or young adults under the age of 25 [12, 13]. The UAV has two anatomical variations. One is a pin-hole shaped acommissural UAV
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and the other is a slit-shaped unicommissural UAV. The acommissural UAV is associated with severe stenosis, with symptoms often presenting at birth. Many patients with this type of
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UAV need to undergo surgical intervention for severe AS during their infancy. The unicommissural UAV is characterized by a relatively larger orifice than the acommissural one and this type is generally asymptomatic and shows normal hemodynamic parameters at birth and in early childhood [7]. The typical age of patients presenting with a symptomatic unicuspid aortic valve is from their early thirties to their sixties [5, 14], which is 10-20 years earlier than for patients with bicuspid aortic valve [5, 13, 15-17].
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ACCEPTED MANUSCRIPT The first successful surgical replacement of a diseased heart valve was reported in 1960. Aortic valve replacement (AVR) has since become the gold standard for surgical treatment of AS [1]. An AVR with a mechanical valve initially provides adequate hemodynamic results, but freedom from reoperation in pediatric patients is only 85% to 90% at 10 years [15].
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Similarly, AVR with a pulmonary autograft carries a risk of reoperation of approximately 10% at 10 years [18]. Aortic valve repair (AVr) has now become an attractive alternative to aortic valve replacement [19-22]. The latest data show that aortic valve repair can be applied
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to a wide spectrum of aortic valve diseases, including stenotic UAV [1, 5, 21, 23-26].
[15, 27].
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The bicuspidization technique was initially described by Hans-Joachim Schäfers in 2008
Here we present our one-institution experience with bicuspidization of stenotic unicuspid aortic valves, with a focus on procedural safety and effects of the repair on hemodynamic
Patients and Methods
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parameters of the diseased valve.
From January 2011 to October 2016, seventeen symptomatic patients underwent an aortic
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valve repair procedure for UAV-associated pathology. All of the patients had unicommisural aortic valve, we did not encounter any acommissural UAV. During the same time period
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another two patients with UAV were operated on, but due to excessive calcifications we accomplished an aortic valve replacement. The chest was opened by a standard median sternotomy in all patients and the patients were placed on cardiopulmonary bypass using ascending aorta and the right atrial cannulation. Blood cardioplegia was administered directly into the coronary ostia. The aorta was transected just above the sinotubular junction. In all patients there was just one physiological posterior commissure. Two other commissures were rudimentary, non/right coronary and left/right
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ACCEPTED MANUSCRIPT coronary, and were displaced 5 to 15 mm lower than the “normal” commissure, i.e. the ostium of the right coronary artery was above the insertion of the rudimentary commissures. The rudimentary commissures and the adjacent calcified areas of the valve were excised, with excision restricted to a maximum of 40 to 50 % of cusp tissue, and the normal commissure
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was preserved. Cusps and a new commissure, opposite to the preserved native commissure, were created by using two triangular patches excised from equine pericardium (Matrix Patch, equine pericardial patch, Auto Tissue Berlin GmbH, Germany) (available at our institution) to
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establish bicuspid design of the aortic valve (Figure 1, Figure 2). In order to avoid the risk of too tight patches and consequently higher gradients, the patches must be high enough, i.e. the
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middle part of the leaflet´s free margin has to be mobile so that it can freely reach the corresponding sinus of the aorta. To avoid prolapse, a significant predictor of reoperation, following valve reconstruction we systematically measured the effective height of both cusps using a commercially available aortic valve caliper (Schäfers, MSS-1, Fehling Instruments,
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Germany). Our target height was 9-10 mm [25] and in cases where prolapse was detected we added centrally-plicated stitches. To avoid ischaemia resulting from proximity to right
from it.
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coronary ostium, the placement of running suture should be at least two millimetres distant
Eight patients with annulus greater or equal to 25 mm [28] underwent the above-
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described valve repair combined with an open extra-aortic ring implantation (Figure 3) to stabilize the aortic annulus and to prevent it from later dilation. The size of the open ring was based on the native aortic annulus diameter measured with Hegar dilator and was created from a Dacron tubular graft. The diameter of the open ring was sized to be one size smaller than the Hegar dilator adjusted to the native annulus, but did not exceed 27 mm. Relatively deep dissection of the aortic root was generally needed. Anchoring of the ring was done with four inside-out circumferentially placed subvalvular “U” pledgeted stitches. Two stitches
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ACCEPTED MANUSCRIPT were placed 2 mm bellow the nadir of each reconstructed cusp and the other two bellow the native anterior and the created posterior commissure. Due to dilated ascending aorta, five patients required adjunctive supracoronary aortic replacement. Echocardiography evaluation was performed prior to surgery and after, before discharge
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and annually during the follow up.
The data are presented as an average ± standard deviation. For statistical analysis a
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Student’s t-test was used and p < 0.05 was used to indicate statistical significance.
Results
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Patients’ baseline characteristics are shown in Table 1. There were 17 patients (9 men) enrolled between February 2011 and December 2016. In two patients aortic insufficiency was the predominant cause for surgery and fifteen patients had pure aortic stenosis. The mean age was 23±5. The average follow-up was 25.9±17.7 months. Mortality was zero during our
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follow-up period. At the time of this publication, the rate of freedom from valve-related reoperation continues to be 100%. We have not encountered any major complications, such as bleeding, thromboembolic events, stroke, infective endocarditis or renal insufficiency
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requiring dialysis. One patient had surgical re-exploration because of higher than expected blood loss postoperatively, with no source of bleeding found and with patient recovering
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fully. All the patients has been discharged with any platelet antiaggregation or anticoagulation therapy.
Preoperative aortic valve area in our patient population varied from 0.6 cm2 to 1.0 cm2, with the average of 0.8 ± 0.1 cm2. Postoperatively, the average aortic valve area increased to 2.8 ± 0.7 cm2 (p<0.01), (Table 2, 3). Mean preoperative systolic gradient ranged from 20 mmHg to 60 mmHg, with an average of 36 ± 13 mmHg, with a significant decrease to a mean gradient of 9 ± 4 mmHg postoperatively (p<0.001), (Table 2, 3). Average preoperative grade
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ACCEPTED MANUSCRIPT of aortic insufficiency was 2.1 ± 1, with statistically significant postoperative decline to 0.6 ± 0.7 (p<0.01), (Table 2, 3). Average preoperative left ventricle end-diastolic diameter (mm) was 49.88±5.11, with statistically significant decrease to 40.46±7.20 at follow-up (p<0.0005), (Table 2, 3). Left ventricle ejection fraction moved up from 56±8.20 to 64±7.83
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preoperatively and at the follow-up, respectively (<0.01), (Table 2, 3). The average diameter of the ascending aorta decreased from 41 ± 7 mm to 29 ± 5 mm pre- and postoperatively, respectively (p<0.01).
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The diameter of the sinotubular junction decreased from 31 ± 5 mm to 25 ± 4 mm preand postoperatively, respectively (p<0.01), the diameter of the aortic root decreased from 32 ±
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5 mm to 28 ± 4 mm pre- and postoperatively, respectively (p<0.01), and the diameter of the aortic annulus decreased from 24 ± 4 mm to 22 ± 3 mm pre- and postoperatively, which was not statistically significant (Table 2).
Mean gradient of 9 ± 4 mmHg postoperatively (before discharge) decreased to a mean
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gradient of 5 ± 3 mmHg at one-year follow-up (p<0.01), (Table 3). Average postoperative grade of aortic insufficiency was 0.6 ± 0.7, which was almost identical with results at oneyear follow-up (0.8±0.6), (Table 3). The average diameter of the ascending aorta
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postoperatively did not show any changes at one-year follow-up (Table 3). We have not encountered any ischaemic complications regarding the placement of the new commisure
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close to the right coronary ostium.
Comment
The prevalence of UAV in general population is 0.02% [5, 10, 14, 20] and in patients undergoing aortic valve surgery the occurrence has been reported as high as 8% [28]. Adult patients with UAV require surgery on average 20 years earlier than those with bicuspid valve pathology [3, 20]. Although UAV may be accompanied by other pathologies, such as aortic
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ACCEPTED MANUSCRIPT dissection, patent ductus arteriosus, coarctation of the aorta, aberrant right subclavian artery, single coronary artery and ventricular septal defect [5, 7, 14, 21, 22, 26, 29, 30], we did not encounter any of those defects in our patients. Valve replacement surgery in patients with UAV requires the use of a mechanical or a
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biological prosthesis, in addition to use of autologous pericardium for cusp repair. With a mechanical prosthesis the cummulative risk of thromboembolic complications and anticoagulation-related hemorrhage can be substantial due to the long-life expectancy. Risk of
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endocarditis has also been reported as an additional risk factor for both the mechanical and biological prosthesis [20, 31]. While a biological prosthesis does not require anticoagulation,
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its lifetime is limited by degeneration of the heterologous biological material, particularly in young, active adults [21].
Other methods for UAV reconstruction have been described. Autologous pericardial patch insertion was first used by Ross in 1963 [32]. Aortic valve repair using autologous
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pericardium for cusps extension has been described by Duran and his coworkers [33]. Ozaki et al. described an independent replacement of 3 cusps by three autologous pericardial cusps (tricuspidization method) and with this technique saw good short- and mid-term results along
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with good valve hemodynamics and a good quality of life without the need for anticoagulation [1, 23, 30]. Vohra et al. described the use of single-patch commisural
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reconstruction for bicuspid aortic valve type 1 with inclomplete fusion of the conjoined cusp. For asymetric valve with a large conjoined cusp and smaller nonconjoined cusp tricuspidalization is favorable [34]. Authors prefere this technique also for UAV with a single normal commisure and 0, 1, or 2 rudimentary raphes, when a neocommisure is created at the raphe localization directly opposite the normal commissure [34]. According to the physiological situation, it is obvious that tricuspidization shows better haemodynamic
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ACCEPTED MANUSCRIPT parameters compared to bicuspidization. We have chosen the bicuspidization technique for its simplicity and reproducibility. Other authors reported good results with bicuspidization technique [12, 15]. Bicuspidization of UAV includes creating a new commissure at the opposite side of the native
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posterior commissure of UAV. Asymmetrical placement of the new commissure, particularly in orientations of less than 140º to the native commisure, has been shown to reduced the midterm durability in repaired bicuspid valves [12, 15, 28]. Therefore, in our work we created a
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symmetrical bicuspid valve design, with a 180º orientation of the commissure in all patients. Our echocardiographic data from the post-operative follow up at 23 months showed excellent
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hemodynamic parameters of the bicuspidized UAV using this technique.
Stability of the bicuspidization technique is dependent on durability of the patch material [20]. Schäfers et al. presented five years freedom from reoperation in 91% using the bicuspidization metod [20].
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As an alternative to autologous pericardium, equine pericardium may be used. The number of patients and years of follow-up still limit any general conclusions regarding the prefered patch material. In the literature there are few data comparing different materials for
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cusp reconstruction and presented results of durability of autologous pericardium and bovine pericardium are simmilar. Nezhad at al. did not present any statistical significance to higher
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freedom from reoperation during 72±42.5 months of follow-up if bovine pericardium was used (95%±5%) in comparison to autologous pericardium (73%±11%) [35]. Other authors presented a case report of a 23 years long-term follow-up of one patient operated with bovine pericardium cusp extension with a good ventricular function and minimal structural valve deterioration [36]. Aortic annulus dilation is one of the risk factors for valve-sparing root replacement failure. Moreover, UAV is associated with aortic annulus dilation much more frequently than
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ACCEPTED MANUSCRIPT BAV (5). Lansac et al. presented that a systematic use of tailor-made ring annuloplasty significantly increases 7-year freedom from valve-related reoperation (p<0.05), aortic regurgitation grade 3 or higher (p<0.05), and major adverse valve-related events (p<0.05) [37]. However, the tailor-made expansible open ring for aortic valve repair is not available on
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the market so far. We used a dacron stripe for this type of repair [37].
In our work, we used equine pericardium (available at our institution) with good results. We had no mortalities and our post-operative hemodynamic data showed good valve function
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at follow-up. Our freedom from reoperation at the time of this publication remains at 100%. The limitations of this study are small number of patients relatively as well as limited follow-
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up.
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Pericardium for Aortic Stenosis. Circ J 2015; 79: 1504.1510. 2.
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Cohn L. Cardiac Surgery in the Adults. New York, Chicago, San Francisco, Lisbon,
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London, Madrid, Mexico City, Milan, New Delhi, San Juan, Seoul, Singapore, Sydney, Toronto: McGraw-Hill Education; 2011: 1472. 3.
Roberts WC, Ko JM. Frequency by decades of unicuspid, bicuspid, and tricuspid aortic valves in adults having isolated aortic valve replacement for aortic stenosis, with or
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without associated aortic regurgitation. Circulation 2005; 111: 920.925. Kawahara Y, Suzuki K, Takahara S, Fukasawa M. Congenital unicuspid aortic valve stenosis in siblings. Gen Thorac Cardiovasc Surg 2014; 62: 567.569. Noly PE, Basmadjian L, Bouhout I, Viet Le VH, Poirier N, El-Hamamsy. New Insights
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Valves. Can J Cardiol 2016; 32: 110.116. Edwards JE. Pathologic aspects of cardiac valvular insufficiencies. AMA Arch Surg 1958; 77: 634.649. 7.
Kang SD, Seol SH, Park BM et al. Incidental diagnosis of the unicuspid aortic valve with ascending aortic aneurysm in an asymptomatic adult. J Cardiovasc Ultrasound 2011; 19: 102.104.
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Ashrafian H, Harling L, Athanasiou T. John Hunter (1728-93) and the earliest description of bicuspid aortic valves. Int J Cardiology 2013; 166: 245.
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Sniecinski RM, Shanewise JS, Glas KE. Transesophageal echocardiography of a unicuspid aortic valve. Anesth Analg 2009; 108: 788.789.
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10. Novaro GM, Mishra M, Griffin BP. Incidence and echocardiographic features of congenital unicuspid aortic valve in an adult population. J Heart Valve Dis 2003; 12: 674.678.
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11. Singh S, Ghayal P, Mathur A et al. Unicuspid Unicommissural Aortic Valve: An Extremely Rare Congenital Anomaly. Tex Heart Inst J 2015; 42: 273.276.
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12. Aicher D, Bewarder M, Kindermann M, Abdul-Khalique H, Schafers HJ. Aortic valve function after bicuspidization of the unicuspid aortic valve. Ann Thorac Surg 2013; 95: 1545.1550.
13. Chester R, Sahni S, Huynh T. A Case of Late Presenting Unicuspid Aortic Valve in a 62-
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Year-Old Female. Echocardiography 2015; 32: 1203.1205.
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15. Schafers HJ, Aicher D, Riodionycheva S et al. Bicuspidization of the unicuspid aortic valve: a new reconstructive approach. Ann Thorac Surg 2008; 85: 2012.2018.
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16. Olivieri LJ, Baba RY, Arai AE et al. Spectrum of aortic valve abnormalities associated with aortic dilation across age groups in Turner syndrome. Circ Cardiovasc Imaging 2013; 6: 1018.1023.
17. Connelly T, Kolcow W, Smyth Y, Veerasingham D. Unicuspid aortic valve presenting with cardiac arrest in an adolescent. BMJ Case Rep 2015; (in press) 18. Elkins RC, Lane MM, McCue C. Ross operation in children: late results. J Heart Valve Dis 2001; 10: 736.741.
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ACCEPTED MANUSCRIPT 19. Liu X, Han L, Song Z, Tan M, Gong D, Xu Z. Aortic valve replacement with autologous pericardium: long-term follow-up of 15 patients and in vivo histopathological changes of autologous pericardium. Interact Cardiovasc Thorac Surg 2013; 16: 123.128. 20. Franciulli M, Aicher D, Radle-Hurst T, Takahashi H, Rodionycheva S, Schafers HJ. Root
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remodeling and aortic valve repair for unicuspid aortic valve. Ann Thorac Surg 2014; 98: 823.829.
21. Lansac E, Di Centa I, Sleilaty G, Lejeune S, Khelil N, Berrebi A, Diakov C, Mankoubi L,
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Malergue MC, Noghin M, Zannis K, Salvi S, Dervanian P, Debauchez M. Long-term
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results of external aortic ring annuloplasty for aortic valve repair. Eur J Cardiothorac
22. Wang Y, Jiang W, Liu J, Li G, Liu Z, Hu X, Dong N. Early surgery versus conventional treatment for asymptomatic severe aortic regurgitation with normal ejection fraction and left ventricular dilatation. European Journal of Cardio-Thoracic Surgery 2017; ezx018.
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doi: 10.1093/ejcts/ezx018
23. Ozaki S, Kawase I, Yamashita H et al. A total of 404 cases of aortic valve reconstruction
147: 301.306.
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with glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg 2014;
24. Bavaria JE, Desai N, Szeto WY et al. Valve-sparing root reimplantation and leaflet repair
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in a bicuspid aortic valve: comparison with the 3-cusp David procedure. J Thorac Cardiovasc Surg 2015; 149: S22.S28. 25. Schafers HJ, Raddatz A, Schmied W et al. Reexamining remodeling. J Thorac Cardiovasc Surg 2015; 149: S30.S36. 26. Yoshitake A, Okamoto K, Yamazaki M, Kimura N, Hirano A, Iida Y, Abe T, Shimizu H. Comparison of aortic arch repair using the endovascular technique, total arch replacement and staged surgery. Eur J Cardiothorac Surg 2017; ezx028. doi: 10.1093/ejcts/ezx028
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ACCEPTED MANUSCRIPT 27. Aicher D, Schafers HJ. Bicuspidization of the regurgitant unicuspid aortic valve. Multimed Man Cardiothorac Surg 2010; 2010: mmcts 2009 004069. 28. Khelil N, Sleilaty G, Palladino M, Fouda M, Escande R, Debauchez M, Di Centa I, Lansac E. Surgical anatomy of the aortic annulus: landmarks for external annuloplasty in
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aortic valve repair. Ann Thorac Surg. 2015 Apr;99(4):1220-6.
29. Dursun M, Yilmaz S, Sayin OA et al. Combination of unicuspid aortic valve, aortic coarctation, and aberrant right subclavian artery in a child: MR imaging and CTA
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findings. Cardiovasc Intervent Radiol 2007; 30: 547.549.
30. Mookadam F, Thota VR, Garcia-Lopez AM et al. Unicuspid aortic valve in adults: a
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systematic review. J Heart Valve Dis 2010; 19: 79.85.
31. Khan S. Long-term outcomes with mechanical and tissue valves. J Heart Valve Dis 2002; 11 Suppl 1: S8.S14.
32. Ross DN. Surgical reconstruction of the aortic valve. Lancet 1963; 1: 571.574.
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33. Ikonomidis JS, Kratz JM, Crumbley AJ, 3rd et al. Twenty-year experience with the St Jude Medical mechanical valve prosthesis. J Thorac Cardiovasc Surg 2003; 126: 2022.2031.
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34. Vohra HA, deKerchove L, Rubay J et al. A simple technique of commissural reconstruction in aortic velve-sparing surgery. J Thorac Cardiovasc Surg 2013; 145:
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882.886.
35. Mosala Nezhad Z, de Kerchove L, Hechadi J et al. Aortic valve repair with patch in nonrheumatic disease: indication, techniques and durability. Eur J Cardiothorac Surg 2014; 46: 997.1005. 36. Evora PRB, Arcencio L, Evora PM et al. Bovine Pericardial Patch Augmentation of One Insufficient Aortic Valve Cusp with Twenty-three-year Positive Clinical Follow-up Independent of the Patch Degeneration. Braz J Cardiovasc Surg 2017; 32: 49.52.
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ACCEPTED MANUSCRIPT 37. Lansac E, Di Centa I, Sieilaty G et al. Remodeling root repair with an external aortic ring
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annuloplasty. J Thorac Cardiovasc Surg 2017; 153: 1033.1042.
Table 1. Characteristics of the group of patients and follow-up (CPB – cardiopulmonary bypass). Number of Patients
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9/8
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Men/Women Age
CPB time
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Min/Max age
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Aortic clamping time
23±5 years 19/35 years 129±27 minutes 108±27 minutes
Follow-up
25.9±17.7 months
Min/Max follow-up
9/75 months
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Table 2. Echocardiographic parameters (LVEF - left ventricular ejection fraction; LVEDD left ventricular end-diastolic diameter).
Before
Preoperatively
p Value
56±8.20
56±7.83
not significant
49.88±5.11
48.87±7.17
not significant
0.8±0.1cm2
2.8±0.7cm2
<0.01
36±13mmHg
9±4mmHg
<0.001
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discharge
LVEF (%)
Average Grade of regurgitation
2.1±1.0
0.6±0.7
<0.01
Mean Aortic annulus diameter
24±4 mm
22±3 mm
not significant
Mean Aortic root diameter
32±5 mm
28±4 mm
<0.01
Mean ST junction diameter
31±5 mm
25±4 mm
<0.01
Ascending Aorta Diameter
41±7 mm
29±5 mm
<0.01
Aortic Valve Area
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LVEDD (mm)
Mean Systolic Gradient
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Table 3. Echocardiographic parameters (1-year follow-up) (LVEF: - left ventricular ejection fraction; LVEDD - left ventricular end-diastolic diameter). Postoperatively
Follow-up
p Value
56±7.83
64±7.83
<0.01
LVEDD (mm)
Aortic Valve Area
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Mean Systolic Gradient
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LVEF (%)
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Grade of regurgitation
Ascending Aorta Diameter
<0.0005
48.87±7.17
40.46±7.20
2.8±0.7cm2
2.7±0.7cm2
not significant
9±4mmHg
5±3mmHg
<0.01
0.6±0.7
0.8±0.6
not significant
29±5 mm
29±5 mm
not significant
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Figure Legends
Figure 1. Perioperative depiction of Unicuspid Aortic Valve Bicuspidization with reconstruction of a new Anterior Commissure (transformation into bicuspid design) (A Posterior Commissure; B1 - Anterior Leaflet; B2 - Posterior Leaflet; C - Right Coronary
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Ostium; D - New Anterior Commissure - above the Right Coronary Ostium). Figure 2. Drawing of Aortic Valve Repair (Bicuspidization technique). Figure 3. Perioperative image of Bicuspidization of Unicuspid Aortic Valve with an Open
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Extra-Aortic Ring (dacron stripe) Implantation (A - Open Extra-Aortic Ring).
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EP
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S0003-4975(18)30051-1
DOI:
10.1016/j.athoracsur.2017.12.031
Reference:
ATS 31280
To appear in:
The Annals of Thoracic Surgery
Received Date: 13 July 2017 Revised Date:
2 November 2017
Accepted Date: 21 December 2017
Please cite this article as: Kolesar A, Toporcer T, Bajmoczi M, Luczy J, Candik P, Sabol F, Aortic Valve Repair of a Stenotic Unicuspid Aortic Valve in Young Patients, The Annals of Thoracic Surgery (2018), doi: 10.1016/j.athoracsur.2017.12.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Aortic Valve Repair of a Stenotic Unicuspid Aortic Valve in Young Patients Running title: Aortic Valve Repair
Adrian Kolesar, MD, PhD, MPH1, Tomas Toporcer, MD, PhD1, Milan Bajmoczi, MD, PhD2,
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Jan Luczy, MD, PhD, MPH1, Peter Candik, MD, PhD, MPH3, Frantisek Sabol, MD, PhD, MPH, MBA1
Clinic of Cardiac Surgery, Eastern Slovak Institute for Cardiovascular Diseases, Ondavska,
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1
Slovakia
Fairbanks Memorial Hospital - Harry & Sally Porter Heart & Vascular Center, Fairbanks,
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2
Alaska 3
Department of Anesthesiology and Intensive Medicine, Eastern Slovak Institute for
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Cardiovascular Diseases, Kosice, Slovakia
Keywords
Aortic Valve
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Aortic Valve Repair, Aortic Valve Congenital abnormalities, Bicuspidization, Unicuspid
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Word count
Corresponding author: Tomas Toporcer, MD, PhD Ondavska 8, Kosice, 04011, Slovakia Email: [email protected]
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ACCEPTED MANUSCRIPT Abstract Background. The unicuspid aortic valve (UAV) is a well-described pediatric congenital abnormality, with incidence of 0.02% in the general population. Bicuspidization has been described as a potential surgical option to repair this defect.
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Methods. Seventeen symptomatic young patients with a unicuspid valve combined with either valve insufficiency or valve stenosis underwent aortic valve bicuspidization procedure using either an equine pericardium. In addition to bicuspidization, eight patients underwent aortic
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ring implantation and five patients underwent supracoronary replacement of the aorta.
Results. Our results show safety of the bicuspidization procedure. There were no mortalities
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during our average follow-up period of 26 months. Freedom from reoperation for any valverelated reason was 100% during this follow-up period. We observed a statistically significant increase in the aortic valve area from 0.8±0.1cm2 to 2.8±0.7cm2 (p<0.01), a statistically significant decrease in the mean systolic pressure gradient from 36±13.3mmHg to 9±4mmHg
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(p<0.001), a statistically significant decrease in aortic insufficiency grade from 2.1±1.0 to 0.6±0.7 (p<0.01) pre- and post-bicuspidization, respectively, and a statistically significant decrease in the left ventricle end-diastolic diameter (mm) from 49.88±5.11 to 40.46±7.20
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(p<0.0005) as well as a statistically significant increase of left ventricle ejection fraction from 56±8.20 to 64±7.83 at the time of follow-up.
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Conclusions. Based on our study, bicuspidization is an attractive surgical option to repair UAV, particularly in young patients who do not want to be subjected to long-term anticoagulation therapy or who refuse a more traditional surgical approach, such as Ross procedure, for reasons described previously.
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ACCEPTED MANUSCRIPT Aortic stenosis (AS) was first described in 1672 when Rayger identified calcified aortic valve cusps at autopsy [1]. The most common cause of AS is a degenerative calcification of the aortic valve. Calcified bicuspid aortic valves represent the most common form of congenital AS [2]. The second most common form of congenital AS is seen with unicuspid
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aortic valve anatomy, which is present in 4-6% of patients undergoing surgery for AS [3, 4, 5].
Unicuspid aortic valve (UAV) is a well-described pediatric congenital abnormality. It
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was first described by Edwards in 1958 [6, 7]. On the other hand, bicuspid aortic valve (BAV) was originally described by John Hunter (the specimens are still available at the Hunterian
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museum at the Royal College of Surgeons in London). Hunter´s son-in-law then published drawings of Hunter´s BAV specimens, but showed no UAV [8]. During embryonic development, the aortic valve is formed from three tubercles, abnormal fusion of which can result in either a unicuspid or a bicuspid aortic valve [9]. UAV incidence has been estimated
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to be only 0.02% in general population [10, 11], but it remains a frequent reason for aortic valve operation in teenagers or young adults under the age of 25 [12, 13]. The UAV has two anatomical variations. One is a pin-hole shaped acommissural UAV
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and the other is a slit-shaped unicommissural UAV. The acommissural UAV is associated with severe stenosis, with symptoms often presenting at birth. Many patients with this type of
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UAV need to undergo surgical intervention for severe AS during their infancy. The unicommissural UAV is characterized by a relatively larger orifice than the acommissural one and this type is generally asymptomatic and shows normal hemodynamic parameters at birth and in early childhood [7]. The typical age of patients presenting with a symptomatic unicuspid aortic valve is from their early thirties to their sixties [5, 14], which is 10-20 years earlier than for patients with bicuspid aortic valve [5, 13, 15-17].
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ACCEPTED MANUSCRIPT The first successful surgical replacement of a diseased heart valve was reported in 1960. Aortic valve replacement (AVR) has since become the gold standard for surgical treatment of AS [1]. An AVR with a mechanical valve initially provides adequate hemodynamic results, but freedom from reoperation in pediatric patients is only 85% to 90% at 10 years [15].
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Similarly, AVR with a pulmonary autograft carries a risk of reoperation of approximately 10% at 10 years [18]. Aortic valve repair (AVr) has now become an attractive alternative to aortic valve replacement [19-22]. The latest data show that aortic valve repair can be applied
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to a wide spectrum of aortic valve diseases, including stenotic UAV [1, 5, 21, 23-26].
[15, 27].
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The bicuspidization technique was initially described by Hans-Joachim Schäfers in 2008
Here we present our one-institution experience with bicuspidization of stenotic unicuspid aortic valves, with a focus on procedural safety and effects of the repair on hemodynamic
Patients and Methods
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parameters of the diseased valve.
From January 2011 to October 2016, seventeen symptomatic patients underwent an aortic
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valve repair procedure for UAV-associated pathology. All of the patients had unicommisural aortic valve, we did not encounter any acommissural UAV. During the same time period
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another two patients with UAV were operated on, but due to excessive calcifications we accomplished an aortic valve replacement. The chest was opened by a standard median sternotomy in all patients and the patients were placed on cardiopulmonary bypass using ascending aorta and the right atrial cannulation. Blood cardioplegia was administered directly into the coronary ostia. The aorta was transected just above the sinotubular junction. In all patients there was just one physiological posterior commissure. Two other commissures were rudimentary, non/right coronary and left/right
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ACCEPTED MANUSCRIPT coronary, and were displaced 5 to 15 mm lower than the “normal” commissure, i.e. the ostium of the right coronary artery was above the insertion of the rudimentary commissures. The rudimentary commissures and the adjacent calcified areas of the valve were excised, with excision restricted to a maximum of 40 to 50 % of cusp tissue, and the normal commissure
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was preserved. Cusps and a new commissure, opposite to the preserved native commissure, were created by using two triangular patches excised from equine pericardium (Matrix Patch, equine pericardial patch, Auto Tissue Berlin GmbH, Germany) (available at our institution) to
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establish bicuspid design of the aortic valve (Figure 1, Figure 2). In order to avoid the risk of too tight patches and consequently higher gradients, the patches must be high enough, i.e. the
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middle part of the leaflet´s free margin has to be mobile so that it can freely reach the corresponding sinus of the aorta. To avoid prolapse, a significant predictor of reoperation, following valve reconstruction we systematically measured the effective height of both cusps using a commercially available aortic valve caliper (Schäfers, MSS-1, Fehling Instruments,
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Germany). Our target height was 9-10 mm [25] and in cases where prolapse was detected we added centrally-plicated stitches. To avoid ischaemia resulting from proximity to right
from it.
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coronary ostium, the placement of running suture should be at least two millimetres distant
Eight patients with annulus greater or equal to 25 mm [28] underwent the above-
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described valve repair combined with an open extra-aortic ring implantation (Figure 3) to stabilize the aortic annulus and to prevent it from later dilation. The size of the open ring was based on the native aortic annulus diameter measured with Hegar dilator and was created from a Dacron tubular graft. The diameter of the open ring was sized to be one size smaller than the Hegar dilator adjusted to the native annulus, but did not exceed 27 mm. Relatively deep dissection of the aortic root was generally needed. Anchoring of the ring was done with four inside-out circumferentially placed subvalvular “U” pledgeted stitches. Two stitches
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ACCEPTED MANUSCRIPT were placed 2 mm bellow the nadir of each reconstructed cusp and the other two bellow the native anterior and the created posterior commissure. Due to dilated ascending aorta, five patients required adjunctive supracoronary aortic replacement. Echocardiography evaluation was performed prior to surgery and after, before discharge
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and annually during the follow up.
The data are presented as an average ± standard deviation. For statistical analysis a
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Student’s t-test was used and p < 0.05 was used to indicate statistical significance.
Results
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Patients’ baseline characteristics are shown in Table 1. There were 17 patients (9 men) enrolled between February 2011 and December 2016. In two patients aortic insufficiency was the predominant cause for surgery and fifteen patients had pure aortic stenosis. The mean age was 23±5. The average follow-up was 25.9±17.7 months. Mortality was zero during our
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follow-up period. At the time of this publication, the rate of freedom from valve-related reoperation continues to be 100%. We have not encountered any major complications, such as bleeding, thromboembolic events, stroke, infective endocarditis or renal insufficiency
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requiring dialysis. One patient had surgical re-exploration because of higher than expected blood loss postoperatively, with no source of bleeding found and with patient recovering
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fully. All the patients has been discharged with any platelet antiaggregation or anticoagulation therapy.
Preoperative aortic valve area in our patient population varied from 0.6 cm2 to 1.0 cm2, with the average of 0.8 ± 0.1 cm2. Postoperatively, the average aortic valve area increased to 2.8 ± 0.7 cm2 (p<0.01), (Table 2, 3). Mean preoperative systolic gradient ranged from 20 mmHg to 60 mmHg, with an average of 36 ± 13 mmHg, with a significant decrease to a mean gradient of 9 ± 4 mmHg postoperatively (p<0.001), (Table 2, 3). Average preoperative grade
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ACCEPTED MANUSCRIPT of aortic insufficiency was 2.1 ± 1, with statistically significant postoperative decline to 0.6 ± 0.7 (p<0.01), (Table 2, 3). Average preoperative left ventricle end-diastolic diameter (mm) was 49.88±5.11, with statistically significant decrease to 40.46±7.20 at follow-up (p<0.0005), (Table 2, 3). Left ventricle ejection fraction moved up from 56±8.20 to 64±7.83
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preoperatively and at the follow-up, respectively (<0.01), (Table 2, 3). The average diameter of the ascending aorta decreased from 41 ± 7 mm to 29 ± 5 mm pre- and postoperatively, respectively (p<0.01).
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The diameter of the sinotubular junction decreased from 31 ± 5 mm to 25 ± 4 mm preand postoperatively, respectively (p<0.01), the diameter of the aortic root decreased from 32 ±
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5 mm to 28 ± 4 mm pre- and postoperatively, respectively (p<0.01), and the diameter of the aortic annulus decreased from 24 ± 4 mm to 22 ± 3 mm pre- and postoperatively, which was not statistically significant (Table 2).
Mean gradient of 9 ± 4 mmHg postoperatively (before discharge) decreased to a mean
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gradient of 5 ± 3 mmHg at one-year follow-up (p<0.01), (Table 3). Average postoperative grade of aortic insufficiency was 0.6 ± 0.7, which was almost identical with results at oneyear follow-up (0.8±0.6), (Table 3). The average diameter of the ascending aorta
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postoperatively did not show any changes at one-year follow-up (Table 3). We have not encountered any ischaemic complications regarding the placement of the new commisure
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close to the right coronary ostium.
Comment
The prevalence of UAV in general population is 0.02% [5, 10, 14, 20] and in patients undergoing aortic valve surgery the occurrence has been reported as high as 8% [28]. Adult patients with UAV require surgery on average 20 years earlier than those with bicuspid valve pathology [3, 20]. Although UAV may be accompanied by other pathologies, such as aortic
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ACCEPTED MANUSCRIPT dissection, patent ductus arteriosus, coarctation of the aorta, aberrant right subclavian artery, single coronary artery and ventricular septal defect [5, 7, 14, 21, 22, 26, 29, 30], we did not encounter any of those defects in our patients. Valve replacement surgery in patients with UAV requires the use of a mechanical or a
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biological prosthesis, in addition to use of autologous pericardium for cusp repair. With a mechanical prosthesis the cummulative risk of thromboembolic complications and anticoagulation-related hemorrhage can be substantial due to the long-life expectancy. Risk of
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endocarditis has also been reported as an additional risk factor for both the mechanical and biological prosthesis [20, 31]. While a biological prosthesis does not require anticoagulation,
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its lifetime is limited by degeneration of the heterologous biological material, particularly in young, active adults [21].
Other methods for UAV reconstruction have been described. Autologous pericardial patch insertion was first used by Ross in 1963 [32]. Aortic valve repair using autologous
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pericardium for cusps extension has been described by Duran and his coworkers [33]. Ozaki et al. described an independent replacement of 3 cusps by three autologous pericardial cusps (tricuspidization method) and with this technique saw good short- and mid-term results along
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with good valve hemodynamics and a good quality of life without the need for anticoagulation [1, 23, 30]. Vohra et al. described the use of single-patch commisural
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reconstruction for bicuspid aortic valve type 1 with inclomplete fusion of the conjoined cusp. For asymetric valve with a large conjoined cusp and smaller nonconjoined cusp tricuspidalization is favorable [34]. Authors prefere this technique also for UAV with a single normal commisure and 0, 1, or 2 rudimentary raphes, when a neocommisure is created at the raphe localization directly opposite the normal commissure [34]. According to the physiological situation, it is obvious that tricuspidization shows better haemodynamic
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ACCEPTED MANUSCRIPT parameters compared to bicuspidization. We have chosen the bicuspidization technique for its simplicity and reproducibility. Other authors reported good results with bicuspidization technique [12, 15]. Bicuspidization of UAV includes creating a new commissure at the opposite side of the native
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posterior commissure of UAV. Asymmetrical placement of the new commissure, particularly in orientations of less than 140º to the native commisure, has been shown to reduced the midterm durability in repaired bicuspid valves [12, 15, 28]. Therefore, in our work we created a
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symmetrical bicuspid valve design, with a 180º orientation of the commissure in all patients. Our echocardiographic data from the post-operative follow up at 23 months showed excellent
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hemodynamic parameters of the bicuspidized UAV using this technique.
Stability of the bicuspidization technique is dependent on durability of the patch material [20]. Schäfers et al. presented five years freedom from reoperation in 91% using the bicuspidization metod [20].
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As an alternative to autologous pericardium, equine pericardium may be used. The number of patients and years of follow-up still limit any general conclusions regarding the prefered patch material. In the literature there are few data comparing different materials for
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cusp reconstruction and presented results of durability of autologous pericardium and bovine pericardium are simmilar. Nezhad at al. did not present any statistical significance to higher
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freedom from reoperation during 72±42.5 months of follow-up if bovine pericardium was used (95%±5%) in comparison to autologous pericardium (73%±11%) [35]. Other authors presented a case report of a 23 years long-term follow-up of one patient operated with bovine pericardium cusp extension with a good ventricular function and minimal structural valve deterioration [36]. Aortic annulus dilation is one of the risk factors for valve-sparing root replacement failure. Moreover, UAV is associated with aortic annulus dilation much more frequently than
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ACCEPTED MANUSCRIPT BAV (5). Lansac et al. presented that a systematic use of tailor-made ring annuloplasty significantly increases 7-year freedom from valve-related reoperation (p<0.05), aortic regurgitation grade 3 or higher (p<0.05), and major adverse valve-related events (p<0.05) [37]. However, the tailor-made expansible open ring for aortic valve repair is not available on
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the market so far. We used a dacron stripe for this type of repair [37].
In our work, we used equine pericardium (available at our institution) with good results. We had no mortalities and our post-operative hemodynamic data showed good valve function
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at follow-up. Our freedom from reoperation at the time of this publication remains at 100%. The limitations of this study are small number of patients relatively as well as limited follow-
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up.
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11. Singh S, Ghayal P, Mathur A et al. Unicuspid Unicommissural Aortic Valve: An Extremely Rare Congenital Anomaly. Tex Heart Inst J 2015; 42: 273.276.
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15. Schafers HJ, Aicher D, Riodionycheva S et al. Bicuspidization of the unicuspid aortic valve: a new reconstructive approach. Ann Thorac Surg 2008; 85: 2012.2018.
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16. Olivieri LJ, Baba RY, Arai AE et al. Spectrum of aortic valve abnormalities associated with aortic dilation across age groups in Turner syndrome. Circ Cardiovasc Imaging 2013; 6: 1018.1023.
17. Connelly T, Kolcow W, Smyth Y, Veerasingham D. Unicuspid aortic valve presenting with cardiac arrest in an adolescent. BMJ Case Rep 2015; (in press) 18. Elkins RC, Lane MM, McCue C. Ross operation in children: late results. J Heart Valve Dis 2001; 10: 736.741.
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ACCEPTED MANUSCRIPT 19. Liu X, Han L, Song Z, Tan M, Gong D, Xu Z. Aortic valve replacement with autologous pericardium: long-term follow-up of 15 patients and in vivo histopathological changes of autologous pericardium. Interact Cardiovasc Thorac Surg 2013; 16: 123.128. 20. Franciulli M, Aicher D, Radle-Hurst T, Takahashi H, Rodionycheva S, Schafers HJ. Root
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22. Wang Y, Jiang W, Liu J, Li G, Liu Z, Hu X, Dong N. Early surgery versus conventional treatment for asymptomatic severe aortic regurgitation with normal ejection fraction and left ventricular dilatation. European Journal of Cardio-Thoracic Surgery 2017; ezx018.
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23. Ozaki S, Kawase I, Yamashita H et al. A total of 404 cases of aortic valve reconstruction
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in a bicuspid aortic valve: comparison with the 3-cusp David procedure. J Thorac Cardiovasc Surg 2015; 149: S22.S28. 25. Schafers HJ, Raddatz A, Schmied W et al. Reexamining remodeling. J Thorac Cardiovasc Surg 2015; 149: S30.S36. 26. Yoshitake A, Okamoto K, Yamazaki M, Kimura N, Hirano A, Iida Y, Abe T, Shimizu H. Comparison of aortic arch repair using the endovascular technique, total arch replacement and staged surgery. Eur J Cardiothorac Surg 2017; ezx028. doi: 10.1093/ejcts/ezx028
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ACCEPTED MANUSCRIPT 27. Aicher D, Schafers HJ. Bicuspidization of the regurgitant unicuspid aortic valve. Multimed Man Cardiothorac Surg 2010; 2010: mmcts 2009 004069. 28. Khelil N, Sleilaty G, Palladino M, Fouda M, Escande R, Debauchez M, Di Centa I, Lansac E. Surgical anatomy of the aortic annulus: landmarks for external annuloplasty in
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aortic valve repair. Ann Thorac Surg. 2015 Apr;99(4):1220-6.
29. Dursun M, Yilmaz S, Sayin OA et al. Combination of unicuspid aortic valve, aortic coarctation, and aberrant right subclavian artery in a child: MR imaging and CTA
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findings. Cardiovasc Intervent Radiol 2007; 30: 547.549.
30. Mookadam F, Thota VR, Garcia-Lopez AM et al. Unicuspid aortic valve in adults: a
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systematic review. J Heart Valve Dis 2010; 19: 79.85.
31. Khan S. Long-term outcomes with mechanical and tissue valves. J Heart Valve Dis 2002; 11 Suppl 1: S8.S14.
32. Ross DN. Surgical reconstruction of the aortic valve. Lancet 1963; 1: 571.574.
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33. Ikonomidis JS, Kratz JM, Crumbley AJ, 3rd et al. Twenty-year experience with the St Jude Medical mechanical valve prosthesis. J Thorac Cardiovasc Surg 2003; 126: 2022.2031.
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34. Vohra HA, deKerchove L, Rubay J et al. A simple technique of commissural reconstruction in aortic velve-sparing surgery. J Thorac Cardiovasc Surg 2013; 145:
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882.886.
35. Mosala Nezhad Z, de Kerchove L, Hechadi J et al. Aortic valve repair with patch in nonrheumatic disease: indication, techniques and durability. Eur J Cardiothorac Surg 2014; 46: 997.1005. 36. Evora PRB, Arcencio L, Evora PM et al. Bovine Pericardial Patch Augmentation of One Insufficient Aortic Valve Cusp with Twenty-three-year Positive Clinical Follow-up Independent of the Patch Degeneration. Braz J Cardiovasc Surg 2017; 32: 49.52.
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ACCEPTED MANUSCRIPT 37. Lansac E, Di Centa I, Sieilaty G et al. Remodeling root repair with an external aortic ring
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annuloplasty. J Thorac Cardiovasc Surg 2017; 153: 1033.1042.
Table 1. Characteristics of the group of patients and follow-up (CPB – cardiopulmonary bypass). Number of Patients
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Men/Women Age
CPB time
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Min/Max age
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Aortic clamping time
23±5 years 19/35 years 129±27 minutes 108±27 minutes
Follow-up
25.9±17.7 months
Min/Max follow-up
9/75 months
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Table 2. Echocardiographic parameters (LVEF - left ventricular ejection fraction; LVEDD left ventricular end-diastolic diameter).
Before
Preoperatively
p Value
56±8.20
56±7.83
not significant
49.88±5.11
48.87±7.17
not significant
0.8±0.1cm2
2.8±0.7cm2
<0.01
36±13mmHg
9±4mmHg
<0.001
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discharge
LVEF (%)
Average Grade of regurgitation
2.1±1.0
0.6±0.7
<0.01
Mean Aortic annulus diameter
24±4 mm
22±3 mm
not significant
Mean Aortic root diameter
32±5 mm
28±4 mm
<0.01
Mean ST junction diameter
31±5 mm
25±4 mm
<0.01
Ascending Aorta Diameter
41±7 mm
29±5 mm
<0.01
Aortic Valve Area
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LVEDD (mm)
Mean Systolic Gradient
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Table 3. Echocardiographic parameters (1-year follow-up) (LVEF: - left ventricular ejection fraction; LVEDD - left ventricular end-diastolic diameter). Postoperatively
Follow-up
p Value
56±7.83
64±7.83
<0.01
LVEDD (mm)
Aortic Valve Area
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Mean Systolic Gradient
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LVEF (%)
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Grade of regurgitation
Ascending Aorta Diameter
<0.0005
48.87±7.17
40.46±7.20
2.8±0.7cm2
2.7±0.7cm2
not significant
9±4mmHg
5±3mmHg
<0.01
0.6±0.7
0.8±0.6
not significant
29±5 mm
29±5 mm
not significant
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Figure Legends
Figure 1. Perioperative depiction of Unicuspid Aortic Valve Bicuspidization with reconstruction of a new Anterior Commissure (transformation into bicuspid design) (A Posterior Commissure; B1 - Anterior Leaflet; B2 - Posterior Leaflet; C - Right Coronary
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Ostium; D - New Anterior Commissure - above the Right Coronary Ostium). Figure 2. Drawing of Aortic Valve Repair (Bicuspidization technique). Figure 3. Perioperative image of Bicuspidization of Unicuspid Aortic Valve with an Open
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Extra-Aortic Ring (dacron stripe) Implantation (A - Open Extra-Aortic Ring).
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