The bicuspid aortic valve (BAV) is the most common congenital cardiac anomaly in the general population, with a prevalence of 1-2%. Valve repair in aortic insufficiency, with or without an associated aortic aneurysm, has gained interest over valve replacement due to the reduced complications associated with prosthetic valves, such as structural degeneration, endocarditis, and hemorrhagic complications arising from anticoagulation. Therefore, the European valvular disease guidelines recommend valve repair in aortic root replacement surgery (reimplantation or remodeling), regardless of the degree of aortic insufficiency (class I), and in isolated aortic insufficiency (class IIb), for both bicuspid and tricuspid valves. 

Valve repair in aortic insufficiency (AI) with BAV has been standardized in several previous publications by the same group (Lansac et al.), according to three different BAV phenotypes based on the diameter of the proximal aorta: 

• Isolated Aortic Insufficiency without Aortic Dilation (Aortic Diameter < 40-45 mm): In addition to leaflet repair, which includes plication of the fused leaflet to equalize the free edge of both leaflets, a simple (subvalvular) or double (subvalvular and sinotubular junction (STJ)) external annuloplasty is performed.
• Aortic Insufficiency with Suprasinusal Ascending Aorta Aneurysm (Root Diameter < 45 mm and Supracoronary Aorta > 45 mm): Leaflet repair is performed along with replacement of the supracoronary ascending aorta, with or without partial aortic root replacement (hemi-remodeling of the non-coronary sinus) and subvalvular external annuloplasty.
• Aortic Insufficiency with Aortic Root Aneurysm (Root Diameter > 45 mm): Leaflet repair is performed along with complete aortic root replacement using the remodeling technique, together with a subvalvular external annuloplasty.

The objective of this study was to evaluate long-term outcomes of valve repair in BAV-related AI with or without associated aortopathy. 

The authors retrospectively analyzed 343 consecutive patients with isolated AI and BAV, with or without aortopathy, who underwent surgery between 2003 and 2020 in four Parisian centers. Clinical and echocardiographic data were evaluated perioperatively and during follow-up. Survival, valve-related reintervention rate, cumulative incidence of AI grade >2+ and >1+, as well as severe structural valve degeneration (mean gradient > 40 mmHg, 20 mmHg increase from discharge, and/or AI grade >2+), were analyzed. Additionally, a subgroup analysis was conducted based on whether STJ stabilization was performed and commissural orientation (symmetrical >160° or asymmetrical <160°). 

Of the 343 patients, 81.3% (279 patients) were able to undergo valve repair. Thirty-day survival was 99.6%, and the 30-day reintervention rate was 1.4%. The mean transvalvular gradient at discharge was 7.7 mmHg. Patients with commissures aligned to a symmetrical orientation had a significantly lower gradient compared to those who did not (7.58 mmHg vs. 9.63 mmHg; p < 0.001). 

At the 10-year mark, survival was 93.9%, similar to that of the general population of the same age and sex. The cumulative incidence of reoperation was 6.3% (n=10), and the incidence of AI grade >2+ was 5.8% (n=9). Severe structural valve degeneration was reported in 10.2% (n=11), with a stroke incidence of 8.0% and a bleeding incidence of 1.5% over 10 years. 

Based on the surgical technique, the authors compared 248 patients with STJ stabilization (isolated valve repair with double external annuloplasty, supracoronary ascending aorta replacement with annuloplasty, or root remodeling with annuloplasty) versus 31 patients in whom STJ stabilization was not performed (isolated valve repair with simple subvalvular annuloplasty). Patients with STJ stabilization had a lower reoperation rate (2.6% vs. 22.5%; p = 0.0018) and AI grade >2+ (1.2% vs. 23.6%; p < 0.001) over nine years. 

Regarding commissural orientation, patients with initial symmetrical orientation (>160°) or who underwent symmetrical commissural adjustment (<160°) had a lower reintervention rate and AI recurrence (AI >2+) compared to those without symmetrical commissural orientation (<160°). 

Bicuspid aortic valve repair, adapted to aortic phenotype and using annuloplasty techniques, is associated with excellent long-term outcomes. Additional STJ stabilization via external annuloplasty and symmetrical commissural adjustment are crucial to achieving durable valve repair outcomes. 

COMMENTARY 

A recent meta-analysis commentary on the SECCE blog suggests that aortic root remodeling is associated with a higher reintervention rate compared to aortic valve reimplantation after four years. This finding, presumably associated with the absence of annular stabilization in the remodeling technique, has led various groups, such as Schäfers and Lansac, to standardize the use of aortic annuloplasty techniques (GoreTex® sutures, external rings, or subcoronary Dacron bands) as an essential component of isolated or concomitant aortic valve repair procedures for associated aortic aneurysms. 

The Lansac group has standardized valve repair for both bicuspid and tricuspid aortic valves according to the accompanying aortic phenotype, incorporating external annuloplasty with a ring or Dacron bands. In this article, Shraer et al. (Lansac group) report the results of valve repair in BAV with different associated aortic phenotypes and perform a subgroup analysis based on the presence or absence of associated STJ stabilization and symmetrical commissural adjustment after repair. Although the patient cohort is considerable, subgroup analyses may have limited statistical power due to smaller sample sizes. 

The main contributions of this article to current evidence on BAV repair can be summarized as follows: 

• Standardization of Surgical Technique: The excellent long-term outcomes in this patient series, with a 10-year survival rate of 93.9% and a low cumulative reintervention rate (6.2%), support a systematic approach to this condition and validate the European clinical guidelines advocating valve repair over replacement in patients with isolated AI with or without associated aortic aneurysm.

• STJ Stabilization: This study identifies the lack of STJ stabilization as a significant risk factor for AI recurrence and reintervention, recommending techniques that stabilize both the aortic annulus and the STJ to improve the durability of this procedure. These techniques include double external annuloplasty in isolated valve repair without aortic dilation, and supracoronary ascending aorta replacement or aortic root remodeling with external annuloplasty in cases of concomitant aortic aneurysm.

• Promotion of a “Symmetrical” Repair: Patients with symmetrical repair (orientation >160°) had a significantly lower transvalvular gradient at discharge and 10-year follow-up compared to those without such symmetry. Additionally, these patients experienced a lower reintervention rate and AI recurrence during follow-up. Symmetrical commissural orientation after BAV repair is an essential factor for improved valve hemodynamics and greater long-term durability, making it a critical objective in this patient subgroup.

REFERENCE: 

Shraer N, Youssefi P, Zacek P, Debauchez M, Leprince P, Raisky O, et al. Bicuspid valve repair outcomes are improved with reduction and stabilization of sinotubular junction and annulus with external annuloplasty. J Thorac Cardiovasc Surg. 2024 Jul;168(1):60-73.e6. doi: 10.1016/j.jtcvs.2022.11.021.