Percutaneous aortic valve replacement: computed tomography scan after valved stent implantation in human cadaver hearts

Computed tomography scans were performed before and after aortic valve resection with consecutive implantation of a valved stent in human hearts with highly calcified aortic valves in situ (n = 2). This demonstrates that the valved stent shows better fitting in the annulus after removal of the native valve.     

An In Vitro Feasibility Study of the Influence of Configurations and Leaflet Thickness on the Hydrodynamics of Deformed Transcatheter Aortic Valve

Clinically, the percutaneous transcatheter aortic valve (TAV) has been reported to be deformed in a noncircular configuration after its implant. The deformation is universal and various, and it leads to serious leakage and durability problems. Even in the same deformation, the leaflets made in different tissue thicknesses may cause different hydrodynamic performances. Simulating the left heart cardiac conditions by a pulse duplicator system, the present study investigated the effects of the aortic annulus deformation and the leaflet tissue thickness on the hydrodynamics of the TAV. Three 22 mm self‐expanding TAV samples were fabricated with three different leaflet thicknesses (0.25, 0.4, 0.55 mm). Every sample was successively deformed to be elliptical, triangular, and undersized circular shapes. The hydrodynamics of the TAV were assessed through a quasi‐physiological artery pulsatile flow duplicator system. The transvalvular pressure difference, effective orifice area, and regurgitation flow were determined. High‐speed video recordings were taken to investigate the leaflet kinematics. The results showed that the triangular deformation produced the poorest valve function while the elliptical deformation led to the slightest difference from the nominal. With increasing leaflet thickness, the effect of configuration deformation on the regurgitation increased. The thinner leaflets were better than the thicker ones in adapting to the deformation but had a higher risk of deterioration.     

Is anterior mitral valve leaflet length important in outcome of septal myectomy for obstructive hypertrophic cardiomyopathy?

ObjectivesElongation of mitral valve leaflets is a phenotypic feature of hypertrophic cardiomyopathy, and some surgeons advocate plication of the anterior leaflet at the time of septal myectomy. The present study investigates mitral valve leaflet length and outcomes of patients undergoing septal myectomy for obstructive hypertrophic cardiomyopathy.MethodsWe reviewed the records and echocardiograms of 564 patients who underwent transaortic septal myectomy for obstructive hypertrophic cardiomyopathy between February 2015 and April 2018. Extended septal myectomy without plication of the anterior leaflet was the standard procedure. From intraoperative prebypass transesophageal echocardiograms, we measured anterior and posterior mitral valve leaflets and their coaptation length. For comparison, we performed these mitral valve leaflet measurements in 90 patients who underwent isolated coronary artery bypass grafting and 92 patients undergoing aortic valve replacement in the same period. Among patients with hypertrophic cardiomyopathy undergoing septal myectomy, we assessed left ventricular outflow tract gradient relief and 1-year survival in relation to leaflet length.ResultsMedian patient age (interquartile range) was 60.3 (50.2-67.7) years, and 54.1% were male. Concomitant mitral valve repair was performed in 36 patients (6.4%), and mitral valve replacement was performed in 8 patients (1.4%), primarily for intrinsic mitral valve disease. Patients in the hypertrophic cardiomyopathy cohort had significantly longer mitral valve leaflet measurements compared with patients undergoing coronary artery bypass grafting or aortic valve replacement (P < .001 for all 3 measurements). Preoperative resting left ventricular outflow tract gradients were not related to leaflet length (<30 mm, median 49 [21, 81.5] mm Hg vs ≥30 mm, 50.5 [21, 77] mm Hg; P = .76). Further, gradient reduction after myectomy was not related to leaflet length; patients with less than 30 mm anterior leaflet length had a median gradient reduction of 33 (69, 6) mm Hg compared with 36.5 (62, 6) mm Hg for patients with leaflet length 30 mm or more (P = .36). Anterior mitral valve leaflet length was not associated with increased 1-year mortality (P = .758).ConclusionsOur study confirms previous findings that patients with hypertrophic cardiomyopathy have slight (5 mm) elongation of mitral valve leaflets. In contrast to other reports, increased anterior mitral valve leaflet length was not associated with higher left ventricular outflow tract gradients. Importantly, we found no significant relationship between anterior mitral valve leaflet length and postoperative left ventricular outflow tract resting gradients or gradient relief. Thus, in the absence of intrinsic mitral valve disease, transaortic septal myectomy with focus on extending the excision beyond the point of septal contact is sufficient for almost all patients.     

Echocardiographic characteristics of the cryopreserved allograft aortic valve replacement assessed by intraoperative transoesophageal echocardiography

Improvements in cryopreservation techniques have made possible excellent long-term results using aortic valve allografts. Few studies, however, have examined the echocardiographic characteristics of allograft aortic valves and postoperative valve function. Aortic allograft function was eveluated in 16 patients by intraoperative transoesophageal echocardiography, postoperative catheterization, and angiography. The mean(s.d.) coaptation zone length of the allograft leaflet was significantly greater (7.3(1.4) mm) than that of the normal aortic valve (3.2(0.8) mm) (P < 0.01). No regurgitation was noted in any patients with coaptation zone length of 7–11 mm (P < 0.01). The increment of the leaflet coaptation zone length did not produce a significant pressure gradient during exercise and appeared to be one of the important mechanisms for the prevention of postoperative aortic regurgitation, because commissural orientations may be distorted in the new aortic position. This finding is consistent with the report that allografts with the largest diameter implantable in the recipient annulus should be selected for use.     

In vitro performance of trans-valve left ventricular assist device installed at aortic valve position

In this study, we developed a trans-valve left ventricular assist device (LVAD) that unites a rear-impeller axial-flow blood pump (AFBP) and a polymer membrane valve placed at the aortic valve position. The diameter and length of the rear impeller AFBP was 12 and 63 mm, respectively. The polymer membrane valve was similar to the jelly-fish valve consisting of a valve leaflet made of silicone rubber (thickness 0.5 mm), valve ring (diameter: 25 mm), and valve spokes. The trans-valve LVAD was examined in a mock circulation. An implantable pulsatile flow (PF) VAD was connected to an atrial reservoir to simulate the left ventricle (LV), and the Hall valve was worn in the inflow port, and the trans-valve LVAD was placed in the outflow port as an outflow valve. When the motor rotational speed increased to 26 400 rpm, the mean aortic flow increased from 4.2 to 5.3 L/min, mean aortic pressure increased from 83.4 to 100 mm Hg, and mean motor current of the implantable PF VAD decreased from 1.18 to 0.94 A (unloading effect on LV −21%). The energy equivalent pressure increased from 85.2 to 102 mm Hg, and surplus hemodynamic energy (SHE) decreased by −15.4% from the baseline. In conclusion, the trans-valve LVAD has an advantage of preserving pulsatility without any complicated mechanism and is a novel and promising LV support device.     

Mitral valve replacement in patients after aortic valve replacement

BACKGROUND: Mitral valve replacement in patients who previously had undergone aortic valve replacement is a technical challenge. The rigid aortic prosthesis limits visualization of the anterior mitral annulus and placement of sutures. METHODS: Reoperative mitral valve replacement was performed in five patients after aortic valve replacement. Two patients underwent resternotomy to allow verification of normal aortic prosthetic valve function. Anterolateral right thoracotomy was used for reentry in the remaining three patients. Exposure of the anterior mitral annulus was accomplished by initial traction on the intact anterior leaflet, with resection of this leaflet only after placement of sutures. RESULTS: All patients survived the surgical procedure and are well 2 to 30 months after operation. In one patient it was impossible to open one cusp of the mitral prosthesis, nor was it possible to rotate the valve. The valve was reimplanted, but sutures were tied only after testing for full free cusp motion. CONCLUSIONS: When appropriate, right thoracotomy incision offers excellent exposure of the mitral valve with minimal dissection. Placement of sutures along the anterior portion of the annulus is facilitated by traction downwards on the anterior leaflet. Full range of motion of the prosthetic cusps should be verified before tying the sutures.     

Early and midterm outcomes of transcatheter aortic valve replacement in patients with bicuspid aortic valves

Background

Bicuspid aortic valve (BAV) stenosis has been considered a relative contraindication to transcatheter aortic valve replacement (TAVR). We compared the outcomes of TAVR in patients with BAV stenosis versus patients with trileaflet aortic valve stenosis.

Methods

From March 2012 to September 2017, 727 patients underwent TAVR. Thirty‐two patients with BAV were included in this study and compared to 96 patients with comparable risk factors (1:3) with a trileaflet aortic valve (TAV). Transesophageal echocardiography was used to estimate post‐TAVR degree of paravalvular leak (PVL).

Results

Mean ± standard deviation Society of Thoracic Surgeons risk was 6.01 ± 3.42 in the BAV group and 6.08 ± 3.76 in the TAV group (P = 0.92). Thirty‐day mortality was 4.2% (N = 4) in the TAV group and 6.25% (N = 2) in the BAV group (P = 0.63). Three (3.1%) patients in the TAV group and two (6.25%) patients in the BAV group developed a post operative stroke (P = 0.59). Following TAVR, mean aortic valve gradient significantly decreased in both TAV (42.56 ± 14.93 vs 9.27 ± 5.57, P < 0.001) and BAV (44.12 ± 11.82 vs 9.03 ± 7.29, P < 0.001) groups. No patient had a severe PVL after TAVR, and only two (2.08%) patients in the TAV group and one (3.12%) patient in the BAV group had moderate PVL (P = 1.0). Patient survival rate at 1 and 2 years was 86% in the BAV group and 90% at 1 and 2 years in the TAV group (P = 0.74).

Conclusions

TAVR in BAV disease is feasible with favorable valve performance. Immediate and mid‐term outcomes of TAVR in patients with BAV are comparable to those with TAV.     

An appraisal of patch enlargement of the small aortic annulus in 33 patients undergoing aortic valve replacement.

To avoid the problem of valve prosthesis/patient mismatch in the late postoperative period, we have adopted patch enlargement of the small aortic annulus in 33 patients having undergone aortic valve replacement since 1975, when the aortic annulus could not accept a large enough prosthesis. The mean age was 40 years, including 2 children aged 4. The technique of patch enlargement utilized was Nicks' method wherein the incision does not extend onto the mitral leaflet. In 31 adult patients, the aortic annulus before enlargement ranged in diameter from 18 to 24 mm with an average of 20.8 mm. After enlargement, the diameter of the annulus was 25.0 mm on average. In 2 children, the mean diameter of the annulus was enlarged from 16.5 mm to 20.5 mm. There were 2 early deaths in the initial series and 2 late deaths. Patch enlargement of the small aortic annulus is a simple, safe, and effective adjunct permitting the insertion of a valve one or two sizes larger than that which could be accommodated by the native annulus.     

Aortic valve replacement with 17-mm St. Jude Medical Regent prosthetic valves for a small calcified aortic annulus in elderly patients

Purpose  

The aim of this study was to investigate the outcome of aortic valve replacement (AVR) performed with a 17-mm St. Jude Medical Regent prosthetic valve (17SJMR) for an aortic annulus ≤19 mm in elderly patients aged ≥65 years.     

Nicks operation for aortic valve dysfunction with pannus formation; report of a case

A 58-year-old female who underwent an aortic valve replacement 3 years ago was admitted to our hospital. She developed dyspnea in a month. Urgent reoperation was scheduled because an echocardiography demonstrated severe aortic valve regurgitation, and because a cinefluoroscopy showed that a leaflet of the prosthetic valve was restricted. Pannus formation from left ventricular outflow tract caused prosthetic valve insufficiency. An ATS 18 aortic prosthesis was replaced after removing old sewing cuff and surrounding tissue of the aortic annulus as much as possible. However, the coronary orifices were partially covered with the prosthesis. The leaflet rubbed onto the left ventricular outflow muscle specially in opening position. Therefore, an annular enlargement was required. In case of re-replacement of prosthetic valve for small aortic annulus, the annulus was at most same size or smaller than it of the previous operation. It was harmful for the patient whose body surface area was 1.74 m2 to utilize smaller prosthesis because of patient-prosthesis mismatch. We conclude that annular enlargement is useful for reoperarion of small aortic annulus associate with left ventricular outflow hypertrophy.     

Aortic valve debridement by ultrasonic surgical aspirator: a word of caution

Aortic stenosis was relieved in 11 patients by ultrasonic debridement of the valve and annulus, while 102 other patients underwent valve replacement for aortic stenosis during 1988. Debridement was selectively applied based on findings of small annulus size (19 mm or less) and extensive calcification. Additional patient characteristics were mean transvalvular gradient of 78 mm Hg, advanced age, and marked left ventricular hypertrophy. Six patients had no residual gradient and 5 others a mean gradient less than 10 mm Hg. There were no complications related to the debridement process. Intraoperative transesophageal Doppler echocardiography demonstrated improved leaflet mobility and elimination of the gradient in all patients and elimination of associated valvular insufficiency in 2 patients. Follow-up echocardiography demonstrated late onset of new valvular regurgitation in 5 patients that was progressive and required reoperation in 3. Thickened, hardened, and retracted valve leaflets with loss of central coaptation were found in all 3 patients who underwent reoperation. Ultrasonic debridement can effectively relieve aortic stenosis, provide an excellent immediate hemodynamic result, and decrease operative time. However, the early occurrence of aortic insufficiency in a high percentage of patients makes it an unacceptable alternative to valve replacement, and the technique should be abandoned as a treatment for severe calcific aortic stenosis.     

Prosthetic aortic valve dysfunction due to projection of the left ventricular outflow septum

Prosthetic valve dysfunction at the aortic position is generally caused by either pannus overgrowth or thrombus or both. We encountered a case with prosthetic valve dysfunction who had undergone an aortic valve replacement 4 years and 5 months before, receiving SJM-HP 21 mm. During the initial operation, a prosthetic valve was implanted parallel to the ventricular septum and slightly up toward the non-coronary sinus (Olin technique) because of a narrow aortic annulus. Before re-do surgery, Doppler echocardiography and cinefluoroscopy showed an incomplete opening of 1 leaflet of the prosthetic valve. At the re-do operation, it was observed that the movement of the anterior leaflet of the prosthetic valve was disturbed by the projecting ventricular septum. After the projecting ventricular septum was excised, SJM-regent 17 mm valve was implanted perpendicular to the septum at the supra-annular position. Postoperative course was uneventful. The postoperative aortic peak pressure gradient decreased to 25 mmHg by Doppler echocardiography.     

Assessment of aortic annulus dimensions for Edwards SAPIEN Transapical Heart Valve implantation by computed tomography: calculating average diameter using a virtual ring method

Objective: Accurate preoperative assessment of the aortic annulus dimensions is critical in patients undergoing transcatheter aortic valve implantation (TAVI) for severe AS. Using multislice computed tomography (MSCT), we evaluated a novel approach to quantify aortic annulus dimensions using cross-sectional area (CSA) assessment and average diameter calculation compared with the commonly applied electronic caliper measurements in patients undergoing transapical implantation of the Edwards SAPIEN Transcatheter Heart Valve. Methods: Seventy-one patients underwent pre-TAVI MSCT with the following dimensions assessed at the level of the most basal attachment points of all three aortic cusps joined by a virtual ring: CSA, calculated average annulus diameter (CAAD), and minimal, maximum, sagittal and coronal diameters. Measurements were compared with post-TAVI MSCT data sets at the level of the ventricular stent ending in 24 patients. Pre-TAVI measurements were compared to those taken post-TAVI. Eligibility to balloon-expandable TAVI was evaluated based on the different measurements. Results: The Edwards SAPIEN valve (23 mm, n = 8; 26 mm, n = 16) was implanted 2.1 ± 1.1 mm below the non-coronary sinus. Pre-TAVI CAAD was 23.0 ± 1.6 mm; post-TAVI CAAD was 23.0 ± 1.1 mm. Post-TAVI CSA was circular in 18 patients (75%) and ovoid in six (25%). Pre- and post-TAVI assessment showed strong correlation for CSA and CAAD (r = 0.835, p < 0.001; r = 0.841, p < 0.001, respectively). Minimal, maximum, coronal and sagittal dimension correlated weakly between pre- and post-TAVI measurements (r = 0.435–0.632, p = 0.001–0.034). Conclusion: Pre-TAVI CSA assessment and average diameter calculation using a virtual ring method is able to predict the post-interventional configuration of the annulus after balloon-expandable TAVI. We regard this approach as the best-available method to select the appropriate prosthesis size for balloon-expandable TAVI. Specific MSCT-based sizing recommendations should be developed.     

In vitro investigation of aortic valve annuloplasty using prosthetic ring devices

Objectives: The remodeling of the dilatated valve annulus with a prosthetic ring for the repair of valve insufficiency is a well-established concept in mitral valve surgery, and may also be suitable for aortic valve reconstruction. In this study, two models of prosthetic aortic annuloplasty devices were investigated. Methods: Fresh porcine aortic roots (n = 16) were investigated in a pulsatile flow simulator after patch dilatation of the annulus and subsequent reconstruction using both an external and an internal prosthetic ring. For each configuration, leakage was determined by ultrasonic flow measurements and leaflet co-aptation by transesophageal echocardiography. In addition, valves’ motions were recorded by high-speed video. Results: By the use of the prosthetic annuloplasty rings, leakage volumes decreased significantly compared with the dilatated root, more pronounced with the intra-annular ring. Similarly, the co-aptation height of the leaflets increased. Pressure gradients were not significantly influenced by the ring application, but leaflet motion patterns changed from the usual trapezoid to a more rectangular opening characteristic, visible at both echocardiographic and high-speed video analysis. Conclusions: The reconstruction of a dilatated aortic valve annulus using external and internal ring devices is feasible and effective for reduction of regurgitation at which the internal ring provides a greater potential to decrease valve insufficiency.     

Allograft aortic valve implantation: techniques for all types of aortic valve and root pathology

The geometry and degree of symmetry of the diseased aortic root and valve dictate the technical method of implantation of the allograft aortic valve. Five methods are available that are suitable for the full range of aortic root disease: the small aortic root with a valve annulus diameter less than 21 mm, the common aortic valve lesions (valve annulus diameter, 21 to 29 mm), the aneurysmal noncoronary sinus, the moderately large annulus (valve annulus diameter greater than 30 mm), and the aneurysmal aortic root and dilated annulus. Implantation methods include the subcoronary technique, miniroot inclusion technique, and aortic root replacement. Technical variations such as valve inversion during implantation, valve rotation, and continuous or interrupted suture methods are important in certain techniques. The allograft aortic valve is a versatile device that can be used in the surgical management of the full range of aortic valve and aortic root pathology.     

Transcatheter heart valve with variable geometric configuration: in vitro evaluation

Clinically, the current transcatheter aortic valve (TAV) technology has shown a propensity for paravalvular leakage; studies have correlated this flaw to increased calcification at the implantation site and with nonideal geometry of the stented valve. The present study evaluated the hydrodynamics of different geometric configurations, in particular the intravalvular considerations. Three TAV devices were made to create a representative, size 26 mm TAV. Hydrodynamics were assessed using a pulse duplicator. The geometries tested were composed of the nominal, elliptical, triangular, and undersized shapes; along with half-constriction, a conformation in which only a portion of the stent was constrained. The TAVs were assessed for transvalvular pressure gradient (TVG), effective orifice area (EOA), and regurgitant fraction. The nominal-sized shape posed a larger TVG (6.2 ± 0.3 mm Hg) than other configurations (P < 0.001) except the undersized valves. EOA of the nominal sized TAV (1.7 ± 0.1 cm(2) ) was smaller than that of the triangular and half-elliptical versions (P < 0.001). The half- and full-undersized geometries had EOAs smaller than the nominal type (P < 0.001). Nominal shape had smaller regurgitation (6.7 ± 1.4%) than all configurations (P < 0.001) except for the half-undersized (4.0 ± 0.7, P < 0.001) with no statistically significant difference from the full-undersized (6.8 ± 1.3, P = 0.724). The testing of variable geometries showed significant differences from the nominal geometry with respect to TVG, EOA, and regurgitant fraction. In particular, many of these nonideal configurations demonstrated an increased intravalvular regurgitation.     

Ventricular septal defect associated with aortic valve incompetence: results of two surgical managements

Aortic valve insufficiency with ventricular septal defect is usually treated by plication of the commissures. However, long-term deterioration is common. We propose a new technique that corrects the aortic annulus dilatation and the leaflet prolapse and reinforces the sinus of Valsalva. Two groups were compared: group I (29 patients) had plication of the prolapsed leaflet(s) and folding of the free edge; group II (26 patients) had triangular resection of the prolapse cusp, annuloplasty, and reinforcement of the aortic wall. The two groups were similar with regarding to preoperative clinical data. There was no perioperative mortality. Primary failure (aortic valve replacement) occurred in 8 patients in group I (28%) and in 2 patients in group II (8%). The rate of secondary failure was 31% in group I and 4% in group II. The actuarial rate of freedom from reoperation at 5 years is 55% in group I and 88% in group II (p less than 0.05). The late mortality was 6.5% in group I and 10.9% in group II (no difference). We conclude that aortic valve insufficiency with ventricular septal defect is a malformation of the aortic leaflets, the annulus, and the sinus of Valsalva, and that the proposed technique offers a better result than the usual methods in terms of residual aortic valve insufficiency.     

Aortic root dilatation may alter the dimensions of the valve leaflets

Objective: Valve-sparing surgery can be used in patients with dilated aortic roots and aortic insufficiency (AI) but has not become a common practice, in part because the spared valve may be incompetent. Our goal was to study how the dimensions of the aortic root and leaflets have changed in such patients. Methods: Fourteen patients with dilated aortic root and AI were examined by transesophageal echocardiography. The annulus diameter, sinotubular junction (STJ) diameter, sinus height, leaflet free-edge length, and leaflet height were measured. Correlations among these dimensions and with the AI grades were explored. Measurements were also made in 19 normal human aortic valves from silicone molds. Results: There was no evident change in the average diameter of the annulus between the normal valves and those in the dilated aortic roots. The STJ diameter was obviously increased in the dilated aortic roots; the aortic sinuses also appeared to be taller and the leaflets larger than normal. The leaflet free-edge length, the leaflet height, and the sinus height were found to increase with the dilated STJ diameter. The degree of AI was not found to correlate well with any of the dimensions measured. Conclusions: The dimensions of the leaflets may change parallel to aortic root dilatation with AI. Therefore, during valve sparing, it may be necessary to correct both the dilatation of the root and the leaflet free-edge length to achieve a competent valve.     

Relation between size of prosthesis and valve gradient: comparison of two aortic bioprosthesis.

OBJECTIVES: The outcome of patients undergoing aortic valve replacement (AVR) may be affected by the influence of prosthesis-patient mismatch on left ventricular mass regression. However, due to the discrepancies in labeled valve size, size of sizer and actual valve dimension, it is difficult to compare different valve types. In order to perform an objective comparison, this study was designed to compare the hemodynamics of the Edwards Lifescience pericardial (ELP) and the Medtronic Mosaic porcine (MM) bioprosthesis between patients receiving the same valve size and between patients with the same aortic annulus diameter. METHODS: This prospective, randomized study was performed on 81 hospital survivors out of 86 patients undergoing AVR with either the ELP (n=39) or the MM (n=42) bioprosthesis. Intra-operative randomization was performed after the surgeon had excised the aortic valve, measured the size of the aortic annulus with three different sizers (ELP, MM and a set of metric sizers), and decided which size he would implant for either of the valve types. All valves were implanted in supra-annular position with the same implantation technique. Echocardiographic follow-up was performed early postoperatively and 6 months thereafter. RESULTS: In 12 (31%) of the patients receiving the ELP-valve, as compared to 3 (7.1%) of the patients receiving the MM-valve, the labeled valve size was smaller than the aortic annulus diameter (P<0.05). Early postoperatively, mean (17.4+/-3.1 vs 20.3+/-3.6 mmHg) and peak gradients (30.1+/-4.8 vs 37.6+/-9.6 mmHg) for the 21 mm ELP-valve were lower than for the 21 mm MM-valve (P<0.05). All other hemodynamic parameters did not show significant differences at any time point. When the same aortic annulus diameter was taken as a reference, there were no significant hemodynamic differences between either valve type at any time point, regardless of the valve size implanted. CONCLUSIONS: This study demonstrates that the hemodynamic performance of the ELP and the MM bioprosthesis are comparable when the same aortic annulus diameter is taken as a reference. The significant variabilities between different valve types with regard to labeled valve size, valve-sizer size and actual valve size have to be taken into account, when hemodynamic comparisons are performed.     

Tricuspidisation of the aortic valve with creation of a crown-like annulus is able to restore a normal valve function in bicuspid aortic valves

Objective: To evaluate the early results of a new method to repair malfunctioning bicuspid aortic valves by creating a tricuspid valve with a crown-like (i.e. anatomic) annulus. Material and methods: Twelve patients (ages from 10 to 27 years) with chronic regurgitation (and flow-dependent stenosis) of a bicuspid aortic valve underwent repair with the principle of creating a tricuspid valve and a crown-like annulus. The fused leaflets were trimmed and reinserted underneath the existing aortic annulus to create one new native cusp. The third leaflet was fashioned out of a xenopericard patch and was inserted underneath the existing annulus as well to restore the crown-like anatomy of a normal aortic annulus. A tricuspid aortic valve with a morphologically normal annulus was thus created, which resulted in improved coaptation of the leaflets. The repair was immediately assessed by transesophageal echocardiography (TEE) with the heart loaded at 50%. In two patients, a second run helped fine-tune the repair. Median cross-clamping time was 82 min. Follow-up ranged from 3 to 46 months (median 13 months). Results: No significant complication occurred. The function of the aortic valve was excellent with trivial or mild regurgitation in 11 patients and moderate regurgitation in 1 patient. There was no stenosis across the valve. The repair remained stable over time. Remodelling of the left ventricle occurred as expected. Conclusions: Aortic valve repair is feasible in some dysfunctioning bicuspid aortic valves. Tricuspidisation of the valve can result in excellent systolic and diastolic functions. The creation of a crown-like annulus results in improved coaptation of the cusps and could lead to more reliable outcome. Although long-term results are needed, this anatomic correction seems to be a good alternative to valvular replacement in certain sub-groups of patients.