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• W3154755756 abstract "The author reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The author reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. I read with great interest the article by Lau and colleagues1Lau C. Wingo M. Rahouma M. Ivascu N. Iannacone E. Kamel M. et al.Valve-sparing root replacement in patients with bicuspid aortopathy: an analysis of cusp repair strategy and valve durability.J Thorac Cardiovasc Surg. 2021; 161: 469-478Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar regarding a root repair (RR) in bicuspid aortopathy. The authors demonstrated that RR, when performed in valves with good cusp quality (associated with no or slightly impaired valve function), offers better results than after repair containing both root and cusp repair. This is actually nothing new, and therefore the question of whether a root repair in roots larger than the human average and associated with competent or nearly competent valves is really necessary has frequently been examined and discussed.2Park C.B. Greason K.L. Suri R.M. Michelena H.I. Schaff H.V. Sundt T.M. Fate of nonreplaced sinuses of Valsalva in bicuspid aortic valve disease.J Thorac Cardiovasc Surg. 2011; 142: 278-284Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 3Milewski R.M. Habertheuer A. Bavaria J.E. Siki M. Szeto W.Y. Krause E. et al.Fate of remnant sinuses of Valsalva in patients with bicuspid and trileaflet valves undergoing aortic valve, ascending aorta, and aortic arch replacement.J Thorac Cardiovasc Surg. 2017; 154: 421-432Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 4Ouzounian M. Feindel C.M. Partial root repair: paths to a middle ground.J Thorac Cardiovasc Surg. 2018; 155: 527-528Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 5Sundt T.M. Understanding why are we doing what we are doing.J Thorac Cardiovasc Surg. 2018; 155: 528-529Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Due to a lack of evidence, this question remains unanswered, and many surgeons have developed specific solutions ranging from conservative to very aggressive approaches.4Ouzounian M. Feindel C.M. Partial root repair: paths to a middle ground.J Thorac Cardiovasc Surg. 2018; 155: 527-528Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,5Sundt T.M. Understanding why are we doing what we are doing.J Thorac Cardiovasc Surg. 2018; 155: 528-529Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar However, there is still another aspect in the article by Lau and colleagues1Lau C. Wingo M. Rahouma M. Ivascu N. Iannacone E. Kamel M. et al.Valve-sparing root replacement in patients with bicuspid aortopathy: an analysis of cusp repair strategy and valve durability.J Thorac Cardiovasc Surg. 2021; 161: 469-478Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar that, in my opinion, makes the described population especially interesting. One should expect that in the patient group without a need for additional cusp repair, all patients would present with no or irrelevant aortic insufficiency (AI) previous to surgery, yet 7 from 51 study patients (14%) had an AI of grade 3+ or even 4+. Currently we are preparing an evaluation of many hundreds of patients who received RR during the past 2 decades at the Cardiovascular Center in Bad Neustadt, Germany. The only root pathology with bicuspid valve in which we were able to abolish the AI by RR alone was aortic dissection. In all remaining patients, the insufficiency could only be abolished by additional cusp repair, regardless of the commissural orientation and the technique used. Moreover, the suitability of aortic root and valve repair in bicuspid aortic valve has frequently been discussed at the forum of Aortic Valve Repair Taskforce by European Association for Cardio-Thoracic Surgery. During many meetings and workshops with live surgeries organized by the Taskforce (chaired by Filip Casselman and Ruggero De Paulis) during past 5 years, there was always the consensus that RR alone cannot abolish a relevant AI in bicuspid aortopathy without any additional approach to the cusps. For this reason, I would kindly ask the authors of the discussed paper1Lau C. Wingo M. Rahouma M. Ivascu N. Iannacone E. Kamel M. et al.Valve-sparing root replacement in patients with bicuspid aortopathy: an analysis of cusp repair strategy and valve durability.J Thorac Cardiovasc Surg. 2021; 161: 469-478Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar to explain how they achieved the abolishment of the relevant AI in their patients without addressing the cusps, especially because they apparently did not include any patients with aortic dissection. Maybe they have used other techniques of repair that they do not define as cusp repair? After all, the surgical video provided in the article demonstrates a decalcification and shaving of the cusp for improvement of its mobility. Is a cusp decalcification not a cusp repair? Valve-sparing root replacement in patients with bicuspid aortopathy: An analysis of cusp repair strategy and valve durabilityThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 2PreviewValve-sparing root replacement using reimplantation techniques is increasingly applied to bicuspid aortopathy. Long-term durability of cusp repair is unclear. We analyze midterm results using a conservative approach to cusp repair. Full-Text PDF Reply from author: In aortic root aneurysms with bicuspid aortic valves, can reimplantation obviate the need for cusp repair?The Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 1PreviewAortic valve and aortic aneurysm repair have remained fascinating topics for aortic surgeons worldwide due to the myriad methods of producing acceptable outcomes using varied and differing techniques. These differences in technique and philosophy apply as much to the aortic valve as they do to the aortic arch and distal aorta. Urbanski's comments1 regarding our techniques with bicuspid aortic valves are greatly appreciated and we agree that many questions with respect to aortic valve repair remain unanswered due to a lack of evidence. Full-Text PDF Reply: Cusp repair to achieve successful sparing of the valve in bicuspid aortopathyThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 1PreviewValve-sparing root replacement has emerged as a successful technique for repair of root aneurysms associated with bicuspid aortic valve anatomy. The ability to spare the valve with this approach stems from the durable annular stabilization it provides along with certain distensibility of the aortic root from the neosinuses resulting in near normal cusp motion.1 Despite correction of root geometry, preexistent cusp prolapse can continue to be seen due to reduction in inter-commissural distance and frequently requires repair. Full-Text PDF" @default.
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• W3154755756 title "Can root repair alone abolish aortic insufficiency in bicuspid aortopathy?" @default.
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