Deep circumferential annuloplasty as an adjunct to repair regurgitant bicuspid aortic valves with a dilated annulus

Background: Failure to address the functional aortic annulus during bicuspid aortic valve (BAV) repair has led to early repair failures. The pathology of regurgitant BAV involves annular dilatation, which is more pronounced anteriorly and deep toward the muscular interventricular septum. In this study, we assessed the results of BAV repair using a strategy of deep circumferential annular support involving the septum in patients with a dilated annulus (> 26mm) and moderate to severe aortic regurgitation (AR). Methods: Between February 1999 and June 2015, 100 patients with regurgitant (>= 2+) BAV and a dilated ventriculoaortic junction (VAJ) (>= 26 mm) underwent repair with an adjunctive circumferential annuloplasty (reimplantation procedure or ring). External root dissection to accommodate the annuloplasty was carried deep onto the anterior aspect of the interventricular septum. Follow up was complete in 96 patients, with a median follow-up of 31 months and a total of 362 patient-years. Cox regression analysis was used to predict recurrence of AR. Results: The mean VAJ diameter was 30 +/- 4mm. Seventy-nine patients exhibited delayed prolapse of the anterior leaflet (conjoined right and left cusps in Siever type 1 or anterior cusp in Siever type 0), and 93 patients underwent reimplantation. In the entire study group, there were no in-hospital deaths, and only 1 patient had 2+ AR on discharge. There was 1 late noncardiac death. At 8 years, freedom from AR >= 2+ was 96.4% and freedom from reoperation was 96.8%. Higher preoperative AR grade, small graft size, and use of a ring were predictive of recurrent AR. Conclusions: Regurgitant BAVs with a dilated annulus display anterior cusp prolapse toward the septum. A deep circumferential annuloplasty may help maintain repair durability.