Outcomes of aortic valve repair in children resulting in bicuspid anatomy: Is there a need for tricuspidization?

Outcomes of aortic valve repair in children resulting in bicuspid anatomy: Is there a need for tricuspidization?


Schulz A, Buratto E, Wallace FRO, Fulkoski N, Weintraub RG, Brizard CP, Konstantinov IE.J Thorac Cardiovasc Surg. 2022 Jul;164(1):186-196.e2. doi: 10.1016/j.jtcvs.2022.01.022. Epub 2022 Jan 26.PMID: 35227498


Take Home Points:

  • Outcomes of aortic valve repair in small children are excellent.
  • Tricuspidization of bicuspid valve is inferior compared to bicuspid repair in terms of chance of reoperation.



Dr. Yasuhiro Kotani

Commentary from Dr. Yasuhiro Kotani (Okayama, Japan), chief section editor of Congenital Heart Surgery Journal Watch: 





Single center retrospective study included 127 patients who underwent aortic valve repair with creation/preservation of bicuspid aortic valve anatomy or tricuspidization of bicuspid valves between 1980 and 2016. Median age was 0.73 years (interquartile range (IQR, 0.1-8.9), and median weight was 8.15 kg (IQR, 3.9-31.7). The cohort included 29 neonates (22.8%), 36 infants (28.3%), and 62 children (48.8%). Repair was performed without a patch in 69 patients (54.3%). Survival at 10 years was 94.8%. Freedom from aortic valve reoperation at 5 and 10 years was 79.9% and 65.6%, respectively. Re-repair was undertaken in 53.7% (22/41). Freedom from aortic valve replacement at 5 and 10 years was 90.3% and 75.8%, respectively. Risk factors for reoperation were age less than 1 year, unicuspid valve, and the presence of Shone complex and concomitant aortic arch repair. There were 107 patients (107/127, 84.25%) with preoperative bicuspid aortic valve morphology that was preserved. They were compared with a separate cohort of 44 patients who underwent tricuspidization of bicuspid aortic valve during the same period. There was no difference in survival or freedom from aortic valve reoperation. However, freedom from aortic valve replacement was lower after tricuspidization with 49.7% versus 75.8% after 10 years (P=0.0118).




This is a retrospective study for aortic valve repair done at Royal Children’s Hospital, Melbourne. They have a large experience of surgical aortic valve for patients with aortic stenosis. Their outcomes are outstanding with freedom from aortic valve replacement after 10 years is 75.8 % even a half of their patients are neonates and infants. This study showed age less than 1 year, unicuspid valve, and concomitant arch procedure was a risk for reoperation. More importantly, they identified bicuspid repair was superior to tricuspidization regarding with a chance of reoperation. This makes sense when looking at figures and video in the manuscript that their techniques for aortic valve repair are excellent. Term of “aortic valve repair” is difficult to interpret as different surgeons use different techniques. So, it is often tricky to only look at numbers of reoperation rate, etc. in the paper. Excellence of this manuscript is that they have beautiful figures to show exactly how they do for aortic valve repair (Figure 2&3). Also, they provide a video that every surgeon can understand their technique visually, not by the description. When looking at these figures and video, you can appreciate that their techniques of aortic valve repair support their excellent results that not all surgeons can reproduce same outcomes. Hence, I understand that their institutional preference to treat patients with aortic stenosis is surgical aortic valve repair.