Bicuspid aortic valve repair with external or subcommissural annuloplasty-echocardiographic prospective trial

Background The incompetent bicuspid aortic valve (BAV) can be repaired using various techniques. This study presents a prospective comparison of external and subcommissural aortic annuloplasty. Methods Fifty consecutive patients (38 males, age: 43.9 +/- 15.8 years) with BAV insufficiency with or without aortic dilatation underwent valve repair in a single institution. They were prospectively allocated to one of two groups based on the aortic annulus stabilization technique: 25 patients were operated on using the subcommissural annuloplasty (SCA) and 25 using the external complete annuloplasty (EA). Transthoracic echocardiography was performed in all patients before the operation and 1 and 3 years after the operation. Moreover, mortality and morbidity at 7 years were evaluated. Results In prospective echocardiographic comparison, EA was associated with smaller diameter of the aortic annulus (24.1 +/- 2.6 mm vs. 25.8 +/- 2.1 mm, p < .05) and lower mean and peak transvalvular gradients (7 +/- 4 mmHg vs. 13 +/- 4 mmHg, p = .02 and 15.3 +/- 9.7 mmHg vs. 20.7 +/- 5.6 mmHg, p = .03, respectively). No patients died or required reoperation due to recurrent insufficiency at 6,81 (interquartile range-0,17) years after the operation. The Kaplan-Meier actuarial freedom from aortic regurgitation (AR) grade >= 2 or gradient > 20 mmHg at 35.1 +/- 3.6 months years was 96% (24 out of 25) for patients who had external annuloplasty and amounted to 76% (19 out of 25) for those who had SCA, p = .05). Conclusions External annuloplasty performed during repair of the BAV is associated with better hemodynamics at medium-term follow-up compared to SCA.