Long-term Results of Differentiated Anatomic Reconstruction of Bicuspid Aortic Valves

This case series analyzes the long-term stability of bicuspid aortic valve repair for survival and the factors associated with repair failure and evaluates whether a differentiated anatomic repair approach may improve repair stability. Question What is the long-term stability of bicuspid aortic valve repair for aortic regurgitation and/or aneurysm, and what are the risk factors associated with valve failure? Findings In this case series of 1024 patients who underwent bicuspid aortic valve repair with a differentiated anatomic repair approach, 15-year survival was 82%. Cusp calcification, asymmetric commissural orientation, and the need for partial cusp replacement were risk factors associated with valve failure. Meaning Bicuspid aortic valve repair with or without concomitant aortic replacement is associated with long-term stability if all pathologic components of the aortic valve and root, including commissural orientation, are addressed. Importance Bicuspid aortic valve (BAV) repair has been used in limited cohorts, but its long-term results in a large population are unknown. Objectives To analyze the long-term stability of BAV repair for survival and the factors associated with repair failure and to evaluate whether a differentiated anatomic repair approach may improve repair stability. Design, Setting, and Participants In this case series, 1024 patients underwent BAV repair for aortic regurgitation or aneurysm between October 1995 and June 2018, with a mean (SD) follow-up time of 56 (49) months and maximum follow-up of 271 months. Systematic modifications in technique based on anatomic principles were introduced in 2009 and applied for the last 727 patients. Data were acquired prospectively and analyzed retrospectively. Exposures Repair of BAV with or without concomitant aortic replacement, as well as postoperative clinical and echocardiographic follow-up. Main Outcomes and Measures Survival and incidence of reoperation or recurrent aortic regurgitation, as well as factors associated with valve repair failure. Results Among the 1024 patients in the study (920 male [89.8%]; mean [SD] age, 47 [13] years [range, 15-86 years]), the survival rate at 15 years was 82.1%. The cumulative incidence of reoperation was 30.7% (95% CI, 22.7%-38.7%) at 15 years. Cusp calcification (subdistribution hazard ratio, 1.78; 95% CI, 1.14-2.77;P = .01), asymmetric commissural orientation (subdistribution hazard ratio, 1.95; 95% CI, 1.02-3.72;P = .04), and use of a pericardial patch for cusp repair (subdistribution hazard ratio, 5.25; 95% CI, 3.52-7.82;P < .001) were associated with time to reoperation. At 10 years, the incidence of reoperation was significantly reduced among patients who received the anatomic repair concept compared with those who had undergone surgery in the earlier period (8.8% vs 24.6%;P < .001). Conclusions and Relevance This study suggests that survival after BAV repair is excellent and that a large proportion of BAV repairs will remain stable. Repair stability can be markedly improved by an anatomic repair concept. Cusp calcification and the need for cusp repair using a patch remain the factors most strongly associated with valve failure. In those instances, valve replacement should be preferred.