Two Different Geometric Orientations for Aortic Neoroot Creation in Bicuspid Aortic Valve Repair with Root Reimplantation

Objective: Bicuspid aortic valve (BAV) represents 2 cusps oriented along a spectrum of equal (180 degrees/180 degrees) or unequal (150 degrees/210 degrees) leaflet surface area distribution along the aortic annular plane. We have taken the approach of respecting the native geometric orientation of the repaired BAV leaflets when creating the aortic neoroot during valve-sparing root reimplantation (VSRR) procedures. We investigated midterm outcomes with this 2-prong approach for VSRR in BAV syndrome. Methods: Of 72 patients in a prospectively maintained BAV repair database, 68 met inclusion criteria: 36 patients had 180 degrees/180 degrees neoroot geometry, and 32 patients had 150 degrees/210 degrees orientation. A multivariate ordinal logistic mixed effects model was performed to study parameters associated with recurrent AI greater than 2+. Results: Preoperative parameters were similar between 180 degrees/180 degrees and 150 degrees/210 degrees groups, except for greater incidence of AI 4+ in the latter (50.0 degrees A [n = 16] vs 8.3% [n = 3]; P < .001). Postoperatively, stroke, renal failure, reoperation for bleeding, and pacemaker rates were 0 in the entire cohort. In-hospital/30-day mortality in the entire cohort was 1.5% (n = 1). Multivariate ordinal logistic mixed effects model showed that preoperative AI greater than 3+ (odds ratio, 0.4; P = .46) and geometric orientation of the aortic neoroot (odds ratio, 3.8; P = .25) were not significantly associated with recurrence of AI greater than 2+. Conclusions: Respecting BAV geometry for VSRR neoroot creation yields excellent midterm outcomes and may minimize conjoint cusp leaflet stress that may occur in "forcing" a 150 degrees/210 degrees type I BAV into a 180 degrees/180 degrees neoroot.