1. TrueRaphe’d Bicuspid aortic valve (BAV) repair with valve-sparing root replacement (VSRR): the state-of-the-art? Thomas G. Gleason, M.D., Forozan Navid, M.D., Wilson Szeto, M.D., Joseph E. Bavaria, M.D. University of Pittsburgh and University of Pennsylvania

2. True BAV with insufficiency Raphe’d BAV with stenosis Variable morphological and clinical phenotypes dictate candidacy for preservation

3. Valve-sparing Root Replacement: Modified Reimplantation Technique Gleason, JTCVS 2005;130:601-3.

4. Valve repair & reimplantation: MRA depicts neosinus creation TricuspidRepaired bicuspid (true) Repaired bicupsid (raphe)

5. Aortic valve repair maneuvers used Central or commissural cusp plication Central or commissural cusp plication Cusp resections (triangular) Cusp resections (triangular) Pericardial patch-leaflet replacement Pericardial patch-leaflet replacement Commissuroplasty Commissuroplasty Leading edge reinforcement/shortening Leading edge reinforcement/shortening Rudimentary commissural release Rudimentary commissural release Annuloplasty Annuloplasty

6. Circulation 2007;116 [suppl I]:I-264-69.

7. Post AV repair (triangular resection, commissuroplasty), root replacement, valve reimplantation. Triangular resection Commissuroplasty

8. Post-repair (triangular resection)

9. 2 VSRR techniques used U Pitt 15 cases all using modified reimplantation technique (tailored graft) (Gleason Root graft sizes 36-42 mm U Pitt 15 cases all using modified reimplantation technique (tailored graft) (Gleason JTCVS 2005;130:601-3.) Root graft sizes 36-42 mm Final internal annular diameter 26.5-31 mm Final internal annular diameter 26.5-31 mm 4 pleats used to create 2 sinuses 4 pleats used to create 2 sinuses 20-26 annular sutures used for annuloplasty 20-26 annular sutures used for annuloplasty Mean cusp depth 19.4 mm Mean cusp depth 19.4 mm 2-7 leaflet maneuvers/case (mean 4/case) 2-7 leaflet maneuvers/case (mean 4/case) HUP 8 cases all using commercial “Valsalva graft” (Cameron Ann Thorac Surg 2006;82:548-53.)

10. Demographics: 23 patients Mean age 45.5 (range 33-66) Mean age 45.5 (range 33-66) 19 male 19 male Procedures performed in all 23 patients: Procedures performed in all 23 patients: VSRR 23 VSRR 23 Complex AV repair 8 Complex AV repair 8 Annuloplasty 15 Annuloplasty 15 Hemiarch replacement 21 Hemiarch replacement 21 Cox-maze III 1 Cox-maze III 1 Max aortic orthogonal diameter 53.7 mm (range 48-65mm) Max aortic orthogonal diameter 53.7 mm (range 48-65mm) Aortic regurgitation Aortic regurgitation 0-trace: 5 pts. 0-trace: 5 pts. 1+ : 8 pts. 1+ : 8 pts. 2+ : 3 pts. 2+ : 3 pts. 3+ : 4 pts. 3+ : 4 pts. 4+ : 3 pts. 4+ : 3 pts.

11. Bicuspid aortic valve repair & reimplantation with VSRR 23 VSRR for BAV and TAA 23 VSRR for BAV and TAA 8 with AV repair 8 with AV repair 15 without AV repair 15 without AV repair 7 true BAV 7 true BAV 16 BAV with raphe 16 BAV with raphe Follow-up (2-68 mos, mean 34 ±4 mos) Follow-up (2-68 mos, mean 34 ±4 mos) 0% mortality 0% mortality 0% stroke 0% stroke 0% PPMs 0% PPMs 0% reoperations 0% reoperations 100% freedom from ≥ 2+ AR 100% freedom from ≥ 2+ AR 8.6% 1+ AR 8.6% 1+ AR 91% 0-trace AR 91% 0-trace AR

12. Assessment for aortic valve repair/VSRR A.A good repair is better than a good (bio)prosthesis i.No anticoagulation ii.Potential for longer (indefinite) durability iii.Potential for better hemodynamic profile B.Pitfalls i.Patient selection ii.Understanding the “pathodynamics” of the valve iii.Technically more difficult