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J Thorac Cardiovasc Surg 2003;125:964-966
© 2003 The American Association for Thoracic Surgery
Brief Communications |
From the Departments of Cardiovascular Surgerya and Pediatric Cardiology,b University Hospital of Geneva, Geneva, Switzerland.
Received for publication July 26, 2002. Accepted for publication Aug 20, 2002. Address for reprints: Jan T. Christenson, MD, PhD, FETCS, Department of Cardiovascular Surgery, University Hospital of Geneva, 24 rue Micheli-du-Crest, CH-1211 Geneva 24, Switzerland (E-mail: jan.christenson{at}hcuge.ch).
Aortic valve insufficiency that develops in association with a ventricular septal defect (VSD) is usually caused by leaflet prolapse. In the event of severe aortic valve insufficiency, several techniques to repair the aortic leaflet prolapse have been described.
1-5 An added problem occurs when the aortic valve is bicuspid. In this report we describe an original technique for transforming a bicuspid aortic valve into a tricuspid valve in a child.
Clinical summary
The patient was a 14-year-old girl who, since 1996, had symptoms of a perimembranous VSD (with an extension just below the aortic annulus) combined with a bicuspid aortic valve and severe aortic valve insufficiency and an elongated and prolapsed posterior leaflet (Laubry-Pezzi congenital malformation). Because of rapid clinical deterioration with increasing dyspnea, she was referred to our center for corrective surgery in May 2002 from Morocco. Preoperative echocardiography revealed a high VSD with subaortic extension and a left-to-right ventricular pressure gradient of 42 mm Hg, together with a severe aortic valve insufficiency and a dilated left ventricle.
Surgical technique
The patient was operated on through a median sternotomy with cardiopulmonary bypass. After transverse opening of the ascending aorta and selective cardioplegia, the aortic valve was inspected. A bicuspid aortic valve with severe prolapse caused by elongation of the posterior leaflet was observed (Figure 1, A) together with a large VSD, which was easily accessible through the aortotomy and through the aortic valve. It was closed with a bovine pericardial patch through the same direct approach.
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, B). The ending of the patch at the free border of the leaflet was secured on both sides with an additional suture. The midportion of the ellipsoidal pericardial patch was then fixed to the aortic wall, thus transforming the false commissure into a true third commissure and the bicuspid valve into a tricuspid valve (ie, tricuspidalization; Figure 1, C). After placement of a Frater stitch, the prolapse of the posterior leaflet was evaluated. The posterior leaflet prolapse was corrected by means a technique of plication and suspension of the free edge along a 2-mm-wide strip of polytetrafluoroethylene* (PTFE) applied from one commissure to the other by using 2 running sutures of a 6-0 monofilament passed up and down through the free edge of the leaflet and the PTFE strip (Figure 1, D). The beginning and end of this suture were at each corresponding commissural level in an extra-aortic position. A circular annuloplasty was performed at the level of the ventriculoaortic junction and tied. A dilator (16F) appropriate to the patient's body surface area was placed through the aortic valve to achieve a perfect leaflet adaptation, so that an aortic annular stenosis would be avoided (Figure 1, E). The aortotomy was closed, and after deairing and hemostasis, the patient was weaned from cardiopulmonary bypass without difficulties. After the aortic valve repair, a dicrotic notch was restored with excellent hemodynamics. There was a minimal gradient of 10 mm Hg over the aortic valve. Immediate transesophageal echocardiography revealed 3 freely moving leaflets with good leaflet coaptation and without any evidence of valvular leak.
The postoperative course was uneventful, and the girl was discharged on the sixth postoperative day. Transthoracic echocardiography on the day of discharge easily identified 3 freely moving aortic leaflets and a perfect valve opening without any valve insufficiency (Figure 2).
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In a young child every effort should be made to perform a valve repair rather than replacing the valve to avoid reoperations and anticoagulation therapy. Several techniques have been described to repair the prolapsed elongated aortic leaflet, whereas transformation of a false commissure into a true commissure, thus creating a tricuspid aortic valve, has not been described earlier. The technique of free edge suspension for correction of aortic insufficiency has been described earlier by Kalangos and associates 4 using a pericardial strip and later by David and associates 5 using a strip of PTFE. In this child we have reconstructed the false commissure and transformed it into a true third commissure in a case of bicuspid aortic valve insufficiency. Together with suspension of the prolapsed posterior leaflet, closure of a high VSD (easily closed through the aortic valve using a patch), and an aortic circular annuloplasty, a tricuspid aortic valve without insufficiency was achieved. Because of the successful aortic valve repair, anticoagulation therapy could be avoided. At early follow-up (2 months), the repair was stable.
Footnotes
*Gore-Tex strip; registered trade name of W. L. Gore & Associates, Inc, Flagstaff, Ariz. 
References
This article has been cited by other articles:
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  D. M. McMullan, G. Oppido, B. Davies, Y. Kawahira, A. D. Cochrane, Y. d'Udekem d'Acoz, D. J. Penny, and C. P. Brizard Surgical strategy for the bicuspid aortic valve: Tricuspidization with cusp extension versus pulmonary autograft J. Thorac. Cardiovasc. Surg., July 1, 2007; 134(1): 90 - 98. [Abstract] [Full Text] [PDF]
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