Unicuspid aortic valve repair with bicuspidization in the paediatric population

Unicuspid aortic valve repair with bicuspidization in the paediatric population.


Matsushima S, Heß A, Lämmerzahl JR, Karliova I, Abdul-Khaliq H, Schäfers HJ.


Eur J Cardiothorac Surg. 2020 Oct 1:ezaa285. doi: 10.1093/ejcts/ezaa285. Online ahead of print.


Take Home Points:


  • Unicuspid aortic valve repair in pediatric patients remains a significant challenge.
  • Bicuspidization is a technique used for repair of unicuspid aortic valves, involving the creation of a second functional commissure using patch material.
  • The technique of bicuspidization appear safe and reproducible in experienced hands, with excellent survival and good freedom from re-intervention.



Commentary from Dr. Luis Quinonez (Boston MA. USA), congenital heart surgery section editor of Journal Watch: This is a review of 60 consecutive patients, ages 1 through 18 years (median 13), with unicuspid aortic valves who underwent aortic valve repair for stenosis, regurgitation, or a combination. Half the patients had undergone a previous valvuloplasties. The repair technique is bicuspidization. The technique involves creation of a second functional commissure opposite the best developed commissure using a combination of detached autologous valve tissue and patch material. The new commissure is created at the same height as the existing one. The concepts of geometric height and effective height are described, where the effective height should be approximately 50% of the geometric height. The geometric height is curved the length of the leaflet from base to free edge and the effective height is the vertical distance between the annulus and free edge. The study spans between 2003-2018 and uses various patch materials and an external suture annuloplasty. Overall survival was 96% at 10 years. Freedom from aortic valve reoperation was 73% at 5 years and 50% at 10 years. The time to reoperation was 0.2 to 13 years (median 5.2).


Significance: Durable repair of unicuspid aortic valves remains a significant challenge in the pediatric population. Replacement options may be limited in younger age groups.


Comment: This reports presents a sizable experience with repair of unicuspid aortic valves in the pediatric population. The technique of bicuspidization has been used by Dr. Schafer’s group in Germany since 2003. It is certain it has gone through several modifications over time. The technique is not described in sufficient detail to apply. Although the age range of the patient’s is wide it is notable that half the patients were under 13 years of age and that 12 of the 60 patients were between 1 and 5 years of age, suggesting the technique can be applied early on even in small annuli. The authors mention that the technique can be applied to an aortic root size is down to 10 mm. Survival for the overall cohort was excellent. The freedom from aortic valve reoperation is very acceptable. Although there were some early failures, the median time of re-intervention was just over 5 years, which would allow enough growth to expand the options for re-repair or replacement. When looking at the patch material used, Gore-Tex performed the worst. Interestingly, fixed autologous pericardium did not perform as well as the other decellularized patches, although the follow-up for the latter is less than 5 years. The results of this study support the notion that in experienced hands unicuspid aortic valve repair can be effectively used “as a bridge to more definitive AVR”. The question remains whether the technique is sufficiently standardized to make it reproducible in less experienced hands.