Comment:
To date, this technique has been used in 30 cases. All patients were undergoing isolated AVNeo procedures. Mean age was 42 y.o. (range 24-60) and 75% were males. None of the patients had a history of major copathologies or surgical history. Mean height was 174 cm (range 162-189 cm) and weight was 71 kg (range 57-85 kg). All patients undergoing AVNeo at our Institute are preoperatively studied with Coronary Computed Tomography (CCT) and Transthoracic Echocardiography (TTE).
In borderline cases (e.g., annulus diameter between 21 and 23 mm), the surgeon should consider on a case-by-case basis whether this strategy might be applicable in relation to the patient’s body surface or whether a standard commissure repositioning procedure would be more appropriate. In all cases of this series, the procedure led to a reduction of a single size of the leaflet. The downsizing has never been reported as excessive, in a single case the reduction has resulted to be not sufficient and the P-stitch had to be removed and repositioned to achieve the optimal result. The portion of the aortic ring treated with the P-stitch was in 17 cases the non-coronary sinus, in 3 cases the right coronary sinus, in 8 case the left coronary sinus. In the remaining 2 cases (patients affected by isolated annulus enlargement), treatment was reserved simultaneously to 2 different sinuses (in both cases LCC and NCC) to obtain a configuration of 3 cusps of 35 mm.
Intraoperative echocardiography showed a perfect continence of the valve and excellent aortic gradients (mean gradient 5 mmHg, range 2-9) in all cases. There were no conversion to prosthetic aortic valve replacement (figure 2).
The pre-discharge echocardiogram always confirmed the intraoperative findings.
In all cases, no major adverse events occurred during surgery and no early postoperative mortality was reported. All patients underwent a clinical and echocardiographic follow-up at 3 months, with findings which were essentially consistent with the echocardiogram performed at discharge. A mild, not significant, further improvement of aortic gradients was reported in two cases (from mean gradient 3 mmHg to 2 mmHg in one case and from 6 mmHg to 5 mmHg in the other one).
The longer follow up for this series of patients is 1 year. For all patients who underwent echocardiogram at one year after surgery, the results were concordant with those found at the 3-month follow-up.