Mid-term Outcome after Minimally Invasive Bicuspid Aortic Valve Repair

Background: Aortic valve repair (AVr) represents the primary treatment for aortic valve regurgitation (AR) particularly in young individuals with bicuspid aortic valve (BAV). However, a minimally invasive approach to AVr is seldomly employed. We conducted a retrospective analysis of our single-center experience with AVr with standardized echocardiography follow-up and a detailed examination of a minimally invasive approach.

Methods: A total of 371 patients with either valve-sparing aortic root surgery, isolated cusp repair, or a combination of both techniques from 01/2016 until 09/2024 were examined. Patients with concomitant surgery requiring a median sternotomy (n = 95; e.g., coronary artery bypass graft) or with tricuspid (n = 143) or unicuspid aortic valves (n = 14) were excluded. 119 patients with BAV subtypes R-L fused (72.0%), R-NC fused (12.7%), and non-fused (11.7%) were identified, with the rest remaining unclassified BAV. Echocardiographic follow-up was conducted at 3–6, 12, and 24 months with a median follow-up of 36.5 (2–88) months. Patients who underwent AVr via a partial upper sternotomy (MIC, n = 87) and complete sternotomy (CS, n = 32) were compared regarding procedural duration, ICU stay, and freedom from re-operation.

Results: Mean age was 40.2 ± 12.3 versus 44.7 ± 11.5 years (MIC versus CS; p = 0.04), 88.5% versus 87.5% male. Mean EuroScore II was 0.9 ± 1.3% versus 1.1 ± 0.7%. MIC patients received 11.5% isolated aortic root surgery (CS = 16.1%) and 16.1% additional cusp repair (CS = 38.7%). 72.4% received isolated cusp repair (CS = 45.2%). Concomitant replacement of the ascending aorta was 18.3 versus 40.7% (MIC versus CS). Mean aortic cross-clamp time (MIC: 78.0 ± 37.3 versus CS: 98.8 ± 37.1 minutes; p < 0.01) and mean ICU stay (MIC: 1.42 ± 1.0 versus CS: 2.5 ± 2.5 days; p = 0.04) were significantly shorter in the MIC group. In-hospital AV reintervention rate was 2.3% (MIC) versus 6.3% (CS) and re-thoracotomy for postoperative bleeding was 3.5% (MIC, 3/87) versus 6.3% (CS, 2/32). In-hospital mortality was 1/87 in the MIC group and 1/32 in the CS group. Mortality during follow-up was 3.4% (MIC, 3/84) versus 3.1% (CS, 1/31). Freedom from AV reintervention after 5 years was 84.3 ± 4.7% (MIC) versus 77.9 ± 11.8% (CS; p = 0.95).

Conclusion: BAV patients can be treated safely with AVr through a partial upper sternotomy leading to a significantly shorter cross-clamp time and ICU stay. No significant difference was identified regarding freedom from AV re-intervention in the MIC group compared with CS.

Publication History

Article published online:
11 February 2025