1. Long terms results after bicuspid aortic valve repair according to functional classification of aortic insufficiency Khalil Fattouch, Giacomo Murana, Sebastiano Castrovinci, Massimo Salardino, Antonio Rubino, Emanuela Clara Bertolino, Giuseppa Caccamo, Roberta Sampognaro, Patrizio Lancellotti, Giovanni Ruvolo

2. -- From February 2003, 66 patients were referred to our institutions for elective AVR repair for regurgitant bicuspid aortic valve -- Clinical and Echocardiographic follow-up was 100% complete. -- Mean follow-up: 40±16 months [range 3 – 82 months] Patients and Methods

3. Patients characteristics Variables patients (%) Age (years) Male gender Diabetes COPD Hypertension Creatinine > 1.5 mg/dl Angina Atrial fibrillation 53±15 50 (75.7%) 6 (9%) 30 (45%) 3 (4.5%) 2 (3%) 4 (6%) Variables patients (%) NYHA Class II III IV 41 (62.1%) 20 (30.3%) 5 (7.6%) Logistic EuroSCORE 5.2±3.1

4. BAV insufficiency according to Functional classification Type I: Normal leaflet motion Type II: Excessive leaflets motion Type III: Restrictive leaflets motion 16 patients (24.2%) 40 patients (60.6%) 10 patients (15%)

5. Intraoperative Data and Surgical Techniques Variables N° of patients (%) Cusp repair : Plication Free edge reinforcement Chordae technique Triangular resection Pericardial patch 30 (45.4%) 25 (37.8%) 10 (15.1%) 8 (12.2) Surgery of root dilatation: Valve reimplantation Supracommissural aortic replacement Sub-commissural plasty 41 (62.1%) 25 (37.9%) 18 (27.2%)

6. Early Results In-hospital deaths was 1.5 % Re-exploration for bleeding was needed in 3 (4.5%) patients The mean postoperative hospital stay was 9±2 days

7. Late Outcomes (%) 1 2 3 4 5 6 years Overall late survival 90.9 %

8. Late Outcomes Freedom from recurrence of AR ≥ grade II was 92.5% (%) 1 2 3 4 5 6 years

9. Type I Type II Type III Percentage of Survival (%) years Freedom from valve-related events according to functional classification p<0.001 Late Outcomes

10. Freedom from valve related-events between the different surgical approach Plication The chordae technique Free edge reinforcement p<0.01 1 2 3 4 5 6 years (%)

11. Late Outcomes Freedom from valve related-events according to type of ascending aorta or root surgery p=0.02 AVR+ root reimplantation AVR+ ascending aorta replacement AVR 1 2 3 4 5 6 (%) years

12. Conclusions  In our experience, BAV can be reproducibly reconstructed with good long term results.  Patients with bicuspid valve and severely calcified raphe have poor outcomes.  Plication or “the chordae technique” improve long term results compared to free edge reinforcement.  Root replacement had better outcomes compared with isolated AVR.