David Operation in the Bicuspid Aortic Valve Population.

INTRODUCTION: Bicuspid aortic valve (BAV) is the single most common cardiac congenital mal-formation with a prevalence of 1-2%. It is frequently associated with aortic disease including annular ectasia. Increasing evidence suggests that valve-sparing root re-implantation surgery combined with primary aortic valve repair can be performed with good midterm results in patients with BAV.

METHODS: Our objective is to compare the short and long term results of David procedure in BAV patients with aortic root ectasia. Retrospective analysis of our institution's database retrieved 42 patients with aortic annular ectasia who underwent valve-sparing root re-implantation surgery with David technic from 2007 to 2015. This cohort included 11 patients with BAV and 31 with tricuspid aortic valve (TAV). Pre, intra and post-operative variables of these two groups were statistically analyzed using univariate analysis. Continuous variables are expressed as means+-standard deviation. Categorical variables are expressed as percentages. Univariate analysis was performed using students t-test for continuous variables and x2 for categorical variables. Long-term survival and freedom from re-intervention was analyzed using Kaplan-Meier curves.

RESULTS: Follow-up was achieved in 100% of cases with an average follow-up of 60 months. Mean age of the studied population was 50 years. Comorbidities and demographics were similar in the BAV and TAV groups with the exception of a younger operative age in the BAV group (p=0,028). Mean cardiopulmonary bypass time and mean ischemic time was 162' and 133' respectively. Combined procedures were performed in 3 (7,1%) of patients. The BAV group showed longer cardio- pulmonary bypass e aortic cross-clamp times (p=0,024; p=0,022) and a universal need for aortic plasty. Short-term results and complications were similar in the two groups with the exception of a higher need for pacemaker implantation in the BAV group (p<0,001). Post-operative results including in-hospital mortality, stroke, AMI, pre-discharge echocardiographic evaluation and long-term survival and freedom from re-intervention were similar between the two groups.

CONCLUSION: Our experience reinforces the idea that, however challenging, the aortic valve sparing re-implantation procedure in the setting of BAV, has acceptable short and long-term results, similar to those observed in TAV patients. The pitfalls of this setting are the universal need for aortic valve plasty and higher risk for AV block. A more significant cohort of patients; echocardiographic long-term evaluation and long-term comparison with the gold-standard technic (Bentall procedure) may further clarify the benefits of this approach in BAV patients.