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• W2996192259 abstract "The concept of “bicuspidization” of the aortic valve is not new and dates back to 1958 in Minneapolis, when Joseph Garamella and colleagues1Garamella J.J. Andersen J.G. Oropeza R. The surgical treatment of aortic insufficiency by open plastic revision of the tricuspid aortic valve to a bicuspid valve.Surg Gynecol Obstet. 1958; 106: 679-686PubMed Google Scholar,2Garamella J.J. Schmidt W.R. Jensen N.K. Lynch M.F. Clinical experiences with the bicuspid operation for aortic regurgitation.Ann Surg. 1963; 157: 310-313Crossref PubMed Scopus (4) Google Scholar described converting an insufficient tricuspid aortic valve to a bicuspid valve by excision of both the noncoronary cusp and a segment of the noncoronary sinus. Later the next year, Thomas Starzl and colleagues3Starzl T.E. Cruzat E.P. Walker F.B. Lewis F.J. A technique for bicuspidization of the aortic valve.J Thorac Cardiovasc Surg. 1959; 38: 262-270Abstract Full Text PDF PubMed Google Scholar described a similar technique in dogs, and then Albert Starr and colleagues4Kadri M.A. Lazzara R.R. McLellan B.A. Starr A. Repair of congenital pulmonary incompetence by bicuspidization of the pulmonary valve.Ann Thorac Surg. 1997; 63: 1482-1483Abstract Full Text PDF PubMed Scopus (3) Google Scholar applied the concept to a severely insufficient pulmonic valve with a congenitally absent posterior cusp. More recently, Luciani and colleagues5Luciani G.B. Morjan M. Faggian G. Mazzucco A. Repair of quadricuspid aortic valve by bicuspidization: a novel technique.Interact Cardiovasc Thorac Surg. 2010; 11: 348-350Crossref PubMed Scopus (19) Google Scholar reported on bicuspidization of a quadricuspid aortic valve, again to address insufficiency. In a bolder application, however, Schäfers and colleagues6Schafers H.J. Aicher D. Riodionycheva S. et al.Bicuspidization of the unicuspid aortic valve: a new reconstructive approach.Ann Thorac Surg. 2008; 85: 2012-2018Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar introduced the concept of bicuspidization for insufficient or stenotic unicuspid valves in 2008, and in this issue of The Annals of Thoracic Surgery, Igarashi and Schäfers and their colleagues7Igarashi T. Matsushima S. Shimizu A. Ehrlich T. Karliova I. Shäfers H.-J. Bicuspidization and annuloplasty provide a functioning configuration to the unicuspid aortic valve.Ann Thorac Surg. 2020; 110: 111-119Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar report their experience with the technique since its introduction. For related article, see page 111 For related article, see page 111 Igarashi and colleagues7Igarashi T. Matsushima S. Shimizu A. Ehrlich T. Karliova I. Shäfers H.-J. Bicuspidization and annuloplasty provide a functioning configuration to the unicuspid aortic valve.Ann Thorac Surg. 2020; 110: 111-119Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar present their series of 137 consecutive cases of conversion of a dysfunctional “unicusp” aortic valve into a functional bicuspid aortic valve by a combination of cusp patch augmentation with creation of a new commissure and “suture annuloplasty” using an annular encircling Gore-Tex (W.L. Gore & Associates, Newark, DE) suture (size 0). These operations were done in predominantly young adults (mean age, 26 years) with moderately severe aortic regurgitation, although the technique was also used in select cases of aortic stenosis (11%). Median echocardiographic follow-up was 4.4 years, and approximately one half that of the median clinical follow-up. The Kaplan-Meier 10-year survival estimate was 96%, and the rate of freedom from aortic valve reoperation was 77% at 5 years and 59% at 10 years. The most common modes of valve failure requiring reoperation were patch degeneration and patch-suture line dehiscence. Collectively, Igarashi and colleagues7Igarashi T. Matsushima S. Shimizu A. Ehrlich T. Karliova I. Shäfers H.-J. Bicuspidization and annuloplasty provide a functioning configuration to the unicuspid aortic valve.Ann Thorac Surg. 2020; 110: 111-119Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar are to be congratulated for their efforts in developing a valve repair strategy for these young patients with these markedly dysmorphic congenital aortic valve abnormalities. This is not the first significant contribution of this team in the realm of aortic valve repair, and thus it comes with distinct credibility. Igarashi and colleagues7Igarashi T. Matsushima S. Shimizu A. Ehrlich T. Karliova I. Shäfers H.-J. Bicuspidization and annuloplasty provide a functioning configuration to the unicuspid aortic valve.Ann Thorac Surg. 2020; 110: 111-119Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar endorse the use of the technique described specifically in the context of the unicommissural form of a “unicusp” aortic valve, terminology introduced by Robert Anderson,8Anderson R.H. Understanding the structure of the unicuspid and unicommissural aortic valve.J Heart Valve Dis. 2003; 12: 670-673PubMed Google Scholar the esteemed morphologist. The desire to develop a durable valve repair strategy for patients with aortic valvular heart disease is paramount for reasons obvious to us all—replacement options, whether mechanical or bioprosthetic, are riddled with inadequacies, especially in the young. Despite significant efforts around the world, aortic valve repair strategies, particularly for more complex disease, such as the valves described in this series, have more commonly fallen short of goal. To that end, the rate of aortic valve reoperation in this series was nontrivial, with the leading 2 causes of valve failure being pericardial patch degeneration and patch-suture line dehiscence. Patch-suture line dehiscence could be caused by suture fatigue and disruption before adequate tissue-to-patch scarring or healing, suture technique, or tissue destruction secondary to an inflammatory process, as can occur in the setting of endocarditis or other localized inflammatory processes. The suture material used for cusp reconstruction was 5-0 polypropylene, which seems more than adequate in this context because other surgeons use this or even finer-caliber suture for cusp repair without demonstration of significant suture fatigue or fracture.9Gleason T.G. Current perspective on aortic valve repair and valve-sparing aortic root replacement.Semin Thorac Cardiovasc Surg. 2006; 18: 154-164Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 10Gleason T.G. Bicuspid aortic valve repair by complete conversion from “raphe’d” (type 1) to “symmetric” (type 0) morphology.J Thorac Cardiovasc Surg. 2014; 148 (e2861-e2862): 2862-2868Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 11Myers P.O. Tissot C. Christenson J.T. Cikirikcioglu M. Aggoun Y. Kalangos A. Aortic valve repair by cusp extension for rheumatic aortic insufficiency in children: long-term results and impact of extension material.J Thorac Cardiovasc Surg. 2010; 140: 836-844Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 12Price J. El Khoury G. Aortic valve insufficiency: leaflet reconstruction techniques.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2012; 15: 3-8Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Alternatively, suture technique itself may be a contributing factor. As shown in Figure 1 of the report by Igarashi and colleagues,7Igarashi T. Matsushima S. Shimizu A. Ehrlich T. Karliova I. Shäfers H.-J. Bicuspidization and annuloplasty provide a functioning configuration to the unicuspid aortic valve.Ann Thorac Surg. 2020; 110: 111-119Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar there may be excess tissue between suture bites that results in a broader differential in distribution of tension across the suture line that could contribute to delayed dehiscence. With respect to pericardial patch degeneration, there is ongoing debate regarding the optimal tissue replacement material for aortic cusp and mitral leaflet augmentation or replacement. Igarashi and colleagues,7Igarashi T. Matsushima S. Shimizu A. Ehrlich T. Karliova I. Shäfers H.-J. Bicuspidization and annuloplasty provide a functioning configuration to the unicuspid aortic valve.Ann Thorac Surg. 2020; 110: 111-119Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar used 1.5% glutaraldehyde-fixed autologous pericardium for the patients included in this report and identified at least 20 patients with patch degeneration at the time of secondary aortic valve reoperation, although there were reoperations required for other reasons before the midterm and until complete follow-up out 10 years. This finding represents a preliminary estimate of patch durability. Igarashi and colleagues,7Igarashi T. Matsushima S. Shimizu A. Ehrlich T. Karliova I. Shäfers H.-J. Bicuspidization and annuloplasty provide a functioning configuration to the unicuspid aortic valve.Ann Thorac Surg. 2020; 110: 111-119Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar have recently changed the patch material that they use to decellularized xenopericardial patch, in the hope that this change will result in a lower degeneration rate. However, a recent report on the use of decellularized bovine pericardium for aortic valve repair in a similar age range of patients demonstrated unsatisfactory results within the first 3 years of follow-up.13Nordmeyer S. Murin P. Schulz A. et al.Results of aortic valve repair using decellularized bovine pericardium in congenital surgery.Eur J Cardiothorac Surg. 2018; 54: 986-992Crossref PubMed Scopus (23) Google Scholar Other decellularized xenograft materials (eg, porcine intestinal extracellular matrix) have been used for bicuspidization of a unicuspid aortic valve and mitral valve leaflet augmentation with similarly high patch failure rates.14Kelley Jr., T.M. Kashem M. Wang H. et al.Anterior leaflet augmentation with CorMatrix porcine extracellular matrix in twenty-five patients: unexpected patch failures and histologic analysis.Ann Thorac Surg. 2017; 103: 114-120Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar,15Mosala Nezhad Z. Baldin P. Poncelet A. El Khoury G. Calcific degeneration of CorMatrix 4 years after bicuspidization of unicuspid aortic valve.Ann Thorac Surg. 2017; 104: e431-e433Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Alternatively, autologous pericardium has been considered for use for valve repair for more than 50 years, with early reports by Donald Ross in London16Ross D.N. Surgical reconstruction of the aortic valve.Lancet. 1963; 1: 571-574Abstract PubMed Scopus (47) Google Scholar and Frater and Ellis and their colleagues in Boston17Frater R.W. Berghuis J. Brown Jr., A.L. Ellis Jr., F.H. The experimental and clinical use of autogenous pericardium for the replacement and extension of mitral and tricuspid value cusps and chordae.J Cardiovasc Surg (Torino). 1965; 6: 214-228PubMed Google Scholar in the early 1960s. Concerns were raised early in that era regarding long-term durability of these repairs using autologous pericardium, and the search was on for identifying other biologic tissue sources for use in valve surgery. Carpentier and Dubost and their colleagues18Carpentier A. Deloche A. Relland J. et al.Six-year follow-up of glutaraldehyde-preserved heterografts. With particular reference to the treatment of congenital valve malformations.J Thorac Cardiovasc Surg. 1974; 68: 771-782Abstract Full Text PDF PubMed Google Scholar,19Carpentier A. Lemaigre G. Robert L. Carpentier S. Dubost C. Biological factors affecting long-term results of valvular heterografts.J Thorac Cardiovasc Surg. 1969; 58: 467-483Abstract Full Text PDF PubMed Google Scholar began experimenting with glutaraldehyde fixation, which went on to widespread use for bioprosthetic valve preservation as we now know it. Since those early days, autologous pericardium for valve repair has gone in and out of favor, and rigorous debate regarding its attributes and deficiencies continues. Glutaraldehyde fixation has been thought by some surgeons to improve autologous pericardial durability in the setting of valve cusp or leaflet augmentation or replacement. Glutaraldehyde invokes stable cross-linking of extracellular matrix proteins, such as collagen, by forming covalent bonds across amino acid residues that may increase structural integrity compared with nonliving fresh pericardium, but whether this translates to longer durability remains unknown. Historical concerns about using fresh autologous pericardium have included (1) patch expansion resulting from a surmised gradual loss of structural integrity, (2) fibrosis and retraction of the tissue causing restriction of motion or loss of cusp/leaflet coaptation, and (3) calcification. However, no adequate in vivo human study directly comparing these indices for fresh relative to fixed pericardium in the context of valve repair has been conducted. In contradistinction to opinions against its use, both remote and recent reports of the use of fresh autologous pericardium in the context of both aortic cusp reconstruction and mitral leaflet reconstruction have demonstrated favorable midterm durability without calcification.10Gleason T.G. Bicuspid aortic valve repair by complete conversion from “raphe’d” (type 1) to “symmetric” (type 0) morphology.J Thorac Cardiovasc Surg. 2014; 148 (e2861-e2862): 2862-2868Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,20Quinn R.W. Wang L. Foster N. et al.Long-term performance of fresh autologous pericardium for mitral valve leaflet repair.Ann Thorac Surg. 2020; 109: 36-41Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar,21Kalangos A. Beghetti M. Baldovinos A. et al.Aortic valve repair by cusp extension with the use of fresh autologous pericardium in children with rheumatic aortic insufficiency.J Thorac Cardiovasc Surg. 1999; 118: 225-236Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Specific handling (to maintain resident cell viability) and tailoring (eg, size and shape) of freshly harvested pericardium, as well as implant technique, may play important roles in optimizing tissue viability to invoke longer-term durability. It is clear from personal experience with tissue culture of resident cells from fresh pericardium that cell viability can be maintained indefinitely in vitro with proper handling. Consequently, it seems evident that tissue viability in vivo, despite tissue transfer and loss of original blood supply, should be possible (as has been demonstrated with other tissues22Olson Jr., J.A. DeBenedetti M.K. Baumann D.S. Wells Jr., S.A. Parathyroid autotransplantation during thyroidectomy. Results of long-term follow-up.Ann Surg. 1996; 223 ([discussion: 478-480]): 472-478Crossref PubMed Scopus (251) Google Scholar,23Wells Jr., S.A. Ellis G.J. Gunnells J.C. Schneider A.B. Sherwood L.M. Parathyroid autotransplantation in primary parathyroid hyperplasia.N Engl J Med. 1976; 295: 57-62Crossref PubMed Scopus (131) Google Scholar), and such viability may impart better durability. In a rare circumstance in which reoperation was required at 4 years after a bicuspid aortic valve repair with nearly total cusp replacement using fresh autologous pericardium, I noted that the reconstructed pericardial cusp was not only viable but also nearly indistinguishable from the adjacent native noncoronary cusp, thus providing direct evidence that fresh autologous pericardium can maintain its viability (Figure 1).10Gleason T.G. Bicuspid aortic valve repair by complete conversion from “raphe’d” (type 1) to “symmetric” (type 0) morphology.J Thorac Cardiovasc Surg. 2014; 148 (e2861-e2862): 2862-2868Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar It may be that the resident cell population has changed in this reconstructed cusp to include both valvular endothelial and valvular interstitial cells, although the cusp was not removed, so the reconstructed cusp’s histologic features are not known. In closing, Igarashi and colleagues7Igarashi T. Matsushima S. Shimizu A. Ehrlich T. Karliova I. Shäfers H.-J. Bicuspidization and annuloplasty provide a functioning configuration to the unicuspid aortic valve.Ann Thorac Surg. 2020; 110: 111-119Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar should be congratulated for their thoughtful approach to these markedly abnormal aortic valves. Historical reflection of the many ideas and iterations aimed at valvular preservation yield an array of structural isomerism of the aortic valve, in this case, bicuspidization redux. Dr Gleason is the national principal investigator for clinical trials for both Abbott and Cytosorbants and serves on a Medical Advisory Board for Abbott. Medtronic and Boston Scientific provide institutional research support on his behalf. Bicuspidization and Annuloplasty Provide a Functioning Configuration to the Unicuspid Aortic ValveThe Annals of Thoracic SurgeryVol. 110Issue 1PreviewThis study reviewed a 12-year experience with a bicuspidization procedure that created a new commissure and added a patch for unicuspid aortic valve repair. Full-Text PDF" @default.
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• W2996192259 title "Structural Isomerism of the Aortic Valve: Bicuspidization Redux" @default.
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