Ventriculoaortic junction remodeling—Holy Grail of bicuspid repair

A very interesting paper dealing with the biomechanical characteristics of annuloplasty during bicuspid aortic valve (BAV) repair highlighted 2 important elements of successful BAV repair: 180 symmetrical configuration and dynamic remodeling of the ventriculoaortic junction. 1The discussion regarding the concept of 180 configuration arose after Aicher and colleagues 2 showed that postoperative commissural asymmetry was the strongest predictor of repair failure.Subsequently, the El-Khoury's group modified their reimplantation technique by tailoring the commissural angle to 180 and proved its reproducibility and effectiveness. 3Annuloplasty with the HAART ring (ie, hemispherical aortic annuloplasty remodelling technology; BioStable Science and Engineering) is the other method that offers a 180 commissural configuration-2 symmetrically opposite commissural posts ensure an ideal valve configuration. 4,5The internal geometric ring provides full 3-dimensional annular stability and ensures commissural orientation at 180 while minimizing the dissection of the aortic root, pulmonary artery, and right ventricle and avoids reimplantation of the coronaries.The success of this approach relates to ventricular aortic junction remodeling.Its aim is to achieve a symmetrical 180 orientation of both fused and nonfused leaflet annuli.The fused leaflet annulus often needs significant reduction from 240 down to 180 .As a result, significant mobility increase can be achieved, resulting in a low gradient, as shown by the BAVr Working Group. 6Interestingly, as shown by Girdauskas and colleagues, 1 annuloplasty techniques are different in addressing dynamical annulus remodeling as a result of the inconsistent nature of muscular and fibrotic annulus.Both external ring annuloplasty and suture annuloplasty do not provide predictable remodeling of stiffer muscular annulus.Therefore, both parts of annulus may require different approaches of stabilization; otherwise, remodeling may not achieve 180 symmetry (Figure 1).The technique of BAV repair with significant attention to ventriculoaortic junction remodeling using both external and internal stabilization has been published as a tutorial by Jasinski 5 (Figure 1).The external annuloplasty covering the basal ring from the left fibrous triangle to the muscular septum provides stabilization of the easily accessed fibrous portion of the annulus, allowing when necessary for easier remodeling of stiffer muscular annulus either by reimplantation or additional internal stabilization.This combined approach may successfully result in continuous gradient amelioration, as shown by the long-term study by Jasinski and colleagues. 7Greater gradient resulting from suboptimal fused leaflet mobilization may, in contrast, hamper long-term durability, as shown by Spadacio and colleagues. 8he authors should be congratulated for bringing up the yet-unresolved issue of optimal techniques of annulus stabilization due to unique biomechanical characteristics of different annular segments, resulting in different postoperative hemodynamics. 1,9