The transition of a normal aortic valve through type 1 into type 0 bicuspid aortic valve.
Central Message.
We present a video that depicts the continuous spectrum of anatomic relationships in normal, type 1, and type 0 bicuspid aortic valves.
See Commentaries on pages 46 and 48.
Bicuspid aortic valve (BAV) disease, classified by Sievers and Schmidtke,1 encompasses a wide span of abnormal anatomy with intermediary configurations including varying states of sclerosis and calcification. Recognition has evolved greatly that the scope of different configurations has significant clinical impact on therapeutic interventions, such as aortic valve repair and transcatheter aortic valve replacement. For example, the circumferential geometric reimplantation of a BAV into a graft during aortic valve repair and valve-sparing aortic root replacement2 has been guided in part by the anatomic configuration of the BAV.3
To advance the understanding of BAV configurations, we employed intraoperative measurements4 and synthesized a video that provides a conceptual dynamic representation of the structural inter-relationship of circumferential angles, cusp fusion length, and commissural fusion height in normal aortic valves, type 1, and type 0 BAVs (Video 1). This video depicts a transition of normal tricuspid aortic valve with a commissure angle of 120° through type 1 with pauses at commissure angle 130°, 150°, and 170° to highlight very asymmetric, asymmetric, and symmetric type 1 BAVs, respectively, and finishes with a 180° type 0 BAV. Note that the pauses in this video do not to convey an actual pathophysiologic event but to convey the presence of a continuous spectrum of anatomic relationships, reflecting the 3 new general BAV categories.3
Video 1.
Animated video that provides a conceptual dynamic representation of the structural inter-relationship of circumferential angles, cusp fusion length, and commissural fusion height in normal aortic valves, type 1, and type 0 bicuspid aortic valves. Video available at: https://www.jtcvs.org/article/S2666-2507(21)00417-X/fulltext.
One can envision how very asymmetric BAVs can be repaired toward a tricuspid configuration, and symmetric BAVs can be repaired toward a 180°/180° configuration and other permutations such as bicuspidization of an unequal tricuspid valve.5 The type 1 BAV configuration was modeled ex vivo and demonstrated clinically relevant aortic regurgitation from fused cusp prolapse, which was successfully repaired.6 This video represents a visual tool that can provide important conceptual understanding of the continuous spectrum of BAV and can aid in the surgical care of this complex patient population.
Footnotes
Disclosures: The authors 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.
Supplementary Data
Animated video that provides a conceptual dynamic representation of the structural inter-relationship of circumferential angles, cusp fusion length, and commissural fusion height in normal aortic valves, type 1, and type 0 bicuspid aortic valves. Video available at: https://www.jtcvs.org/article/S2666-2507(21)00417-X/fulltext.
References
- 1.Sievers H.H., Schmidtke C. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg. 2007;133:1226–1233. doi: 10.1016/j.jtcvs.2007.01.039. [DOI] [PubMed] [Google Scholar]
- 2.Paulsen M.J., Imbrie-Moore A.M., Baiocchi M., Wang H., Hironaka C.E., Lucian H.J. Comprehensive ex vivo comparison of 5 clinically used conduit configurations for valve-sparing aortic root replacement using a 3-dimensional-printed heart simulator. Circulation. 2020;142:1361–1373. doi: 10.1161/CIRCULATIONAHA.120.046612. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Jahanyar J., el Khoury G., de Kerchove L. Commissural geometry and cusp fusion insights to guide bicuspid aortic valve repair. J Thorac Cardiovasc Surg Tech. 2021;7:83–92. doi: 10.1016/j.xjtc.2020.12.043. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.de Kerchove L., Mastrobuoni S., Froede L., Tamer S., Boodhwani M., van Dyck M. Variability of repairable bicuspid aortic valve phenotypes: towards an anatomical and repair-oriented classification. Eur J Cardiothorac Surg. February 20, 2019:ezz033. doi: 10.1093/ejcts/ezz033. [DOI] [PubMed] [Google Scholar]
- 5.Woo Y.J., Frederick J.R. Valve-sparing aortic root replacement and neochordal repair of complex aortic leaflet pathology for ruptured sinus of Valsalva aneurysm fistulizing to the right ventricle. Ann Thorac Surg. 2013;96:1891–1893. doi: 10.1016/j.athoracsur.2013.05.008. [DOI] [PubMed] [Google Scholar]
- 6.Zhu Y., Imbrie-Moore A.M., Paulsen M.J., Priromprintr B., Wang H., Lucian H.J. Novel bicuspid aortic valve model with aortic regurgitation for hemodynamic status analysis using an ex vivo simulator. J Thorac Cardiovasc Surg. June 29, 2020 doi: 10.1016/j.jtcvs.2020.06.028. [Epub ahead of print] [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Animated video that provides a conceptual dynamic representation of the structural inter-relationship of circumferential angles, cusp fusion length, and commissural fusion height in normal aortic valves, type 1, and type 0 bicuspid aortic valves. Video available at: https://www.jtcvs.org/article/S2666-2507(21)00417-X/fulltext.