Bicuspid aortic valve repair with external subannular ring: a case report

Annuloplasty is a key component of bicuspid aortic valve (BAV) repair for severe aortic insufficiency (AI). Reduction of the annular diameter enhances leaflet coaptation, while annular stabilization prevents subsequent dilation, which can lead to recurrent AI and repair failure. Several techniques have been described, including valve-sparing root reimplantation (VSRR), subcommissural annuloplasty (SCA), suture annuloplasty, and external subannular ring (ESAR). At our institution, BAV repair with VSRR is performed in patients with severe AI and an aortic root aneurysm (>4.5 cm). For those presenting with a BAV and severe AI without root enlargement, concomitant SCA is performed when the preoperative annulus is <= 27 mm, while ESAR is employed when the annulus measures >27 mm. A 44-year-old male with known BAV presented to our institution with severe AI and in New York Heart Association (NYHA) Class III heart failure. Pre-procedure transesophageal echocardiogram revealed an annular measurement of 34 mm. Intraoperative inspection of the aortic valve showed a left-right Sievers 1 phenotype with severe calcification confined to the raphe. A BAV repair was performed, which consisted of debridement of calcium from the raphe, triangular resection of the conjoined leaflet, and ESAR. The patient was discharged home after an uneventful post-operative course. At 3-year follow-up, surveillance echocardiogram showed a durable repair without AI and normal left ventricular function. This case report and associated surgical video demonstrates our step-by-step approach to primary BAV cusp repair with an ESAR.