Page 30 - BH-3-3

Brain & Heart Modern imaging and management of bicuspid valves

Concomitant aortic surgery is often required in patients 10 years when external annuloplasty was employed. In
98
with aortic valve disease, particularly when the aortic root a study involving nearly 1,200 patients with BAV without
or ascending aorta is involved. The Bentall procedure severe stenosis, valve preservation was achieved in
is commonly performed for patients with aortic root approximately 90% of cases. The most common causes
99
aneurysms or aortic dissection, combining AVR with the of repair failure were valve calcification and endocarditis.
reimplantation of the coronary arteries into a prosthetic Anatomical factors such as symmetric cusp prolapse,
aortic root. This procedure is essential in cases of aortic annular dilation, utilization of pericardial patches for
92
root dilation or dissection, where there is a risk of rupture partial cusp reconstruction, and the application of
or further complications. The David procedure, also known conventional repair techniques in BAVs with commissural
as aortic valve-sparing surgery, is another option, which angles below 160° have all been associated with surgical
involves reimplanting the aortic valve into a resected aortic repair failure. 100
root. This procedure preserves the patient’s native valve
73
and is typically used in patients with aortic root disease 5.5. Transcatheter management
but without significant valve pathology. Alternatively, the Less invasive alternatives are increasingly being considered
Yacoub procedure, also known as aortic root remodeling, for elderly or high-risk patients who may not be suitable
involves replacing the aortic root while preserving the candidates for SAVR. TAVR is challenging in patients
native aortic valve. This technique reshapes the aortic with BAV, as they often have a non-circular annulus and
root to restore normal valve function without replacing heavier calcification extending into the left ventricular
the valve itself. A study by Schäfers et al. suggested that outflow tract. Registry studies in low-surgical-risk patients
93
the Yacoub procedure for dilatation of the ascending aorta with BAV have demonstrated no significant differences
is superior to the David procedure in patients with BAV; in 1-year mortality or stroke rates when compared to
however, they noted that they have never attempted the tricuspid AS patients treated with TAVR. Yoon et al.
102
101
David procedure in patients with BAV, citing anticipated showed that patients with BAV undergoing TAVR with
significant difficulties in achieving a perfect root and newer-generation devices achieved procedural outcomes
valve geometry with this anatomic variant. Despite these comparable to tricuspid AS patients, with similar
concerns, the AATS supports using the David procedure cumulative all-cause mortality rates at 2 years. Notably,
93
in patients with BAV, noting its technical challenges but new-generation devices were not associated with any
favorable outcomes when performed in high-volume instances of moderate-to-severe paravalvular regurgitation,
centers. In cases of aortic dissection, ascending aorta in contrast to an 8.5% incidence observed with earlier-
94
repair is necessary to address the tear and prevent rupture. generation valves. Unlike surgical valves, transcatheter
102
This repair may involve replacing the affected segment of valves introduce challenges of aligning commissures
the aorta with a synthetic graft. Aortic dissection surgery and coronary access. Advancements in next-generation
95
often requires careful management of blood pressure and TAVR devices and standardized implantation techniques
cardiac function to minimize the risk of complications have significantly reduced issues with coronary access
during and after surgery. Concomitant aortic surgery is seen in earlier designs. 103-105 The strengths and limitations
critical in managing these complex aortic conditions, of various intervention modalities for BAV disease are
ensuring the integrity of the aorta, and improving long- detailed in Table 3.
term outcomes for affected patients. 96
The Lotus Valve System offers advantages such as
BAV without significant valve thickening or mechanically controlled expansion and an adaptive
calcification may be more amenable to surgical repair than seal, which reduce the risk of elliptical deployment
replacement when performed by skilled surgeons with and paravalvular leak. Preliminary data indicate good
specialized training at high-volume centers with expertise outcomes with the Lotus Valve System in BAV anatomies,
in aortic valve procedures. Over 20 years, Schneider et al. suggesting it could be a viable option for these patients.
97
106
evaluated 357 patients who underwent bicuspid AVR with In addition, newer-generation TAVR devices, such as
root remodeling. They reported that 24 patients required the Sapien 3 and Evolut R have demonstrated improved
reoperation for recurrent AR, and six for recurrent aortic procedural success and reduced complications compared
AS, resulting in a cumulative reoperation incidence of to earlier devices. 102,107
21.7% at 15 years. 97
The BEAT registry was a multicenter international study
In the AVIATOR registry, 177 patients underwent of 353 patients with BAV stenosis who underwent TAVR
AVR using root remodeling combined with external aortic with newer, second-generation transcatheter heart valves
annuloplasty; 33.6% had BAV. Notably, the BAV cohort (Sapien 3 or Evolut R/PRO) between 2013 and 2018. In
demonstrated a 100% freedom from reintervention at an analysis of the BEAT registry by Lelasi et al., patients
108

Volume 3 Issue 3 (2025) 11 doi: 10.36922/BH025050008