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\begin{document}

\title{Reply to Jasinski M et al.: \selectlanguage{ngerman}´Indeed, there is still room for improvement
in long\selectlanguage{english}-term durability of BAV repair'\selectlanguage{english}}



\author[1]{Tomas Holubec}%
\author[1]{Mojyan Safari}%
\author[1]{A Vanlinden}%
\author[1]{Anton Moritz}%
\affil[1]{Klinikum der Johann Wolfgang Goethe-Universitat Frankfurt}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\textbf{Title page}

\textbf{Title:} Reply to Jasinski M et al.: \selectlanguage{ngerman}´Indeed, there is still room
for improvement in long\selectlanguage{english}-term durability of BAV repair'

\textbf{Authors:} Tomas Holubec, MD, PhD, Mojyan Safari, MD, Arnaud Van
Linden, MD, Anton Moritz, MD

\textbf{Institutions and Affiliations:} Department of Cardiovascular
Surgery, University Hospital Frankfurt and Goethe University Frankfurt,
Frankfurt, Germany

\textbf{Corresponding author:} Assoc. Prof. Tomas Holubec, MD, PhD,
Theodor-Stern-Kai 7, 60596 Frankfurt/Main, Germany, Tel.: +49 69 6301
80094, Email: tomasholubec@email.cz

\textbf{Word count:}

\textbf{Keywords:} Bicuspid aortic valve; Aortic valve repair; Aortic
valve\selectlanguage{english}-sparing

\textbf{Text}

To the Editor,

we read the letter to the editor by Dr Jasinski et al. entitled
'Long\selectlanguage{english}-term durability of valve\selectlanguage{english}-sparing or repair procedures in BAV -- Is
there room for improvement?' with great interest.\textsuperscript{1} We
thank Dr Jasinski et al. for their valuable comments and question on our
manuscript entitled `Longer\selectlanguage{english}-term outcomes after bicuspid aortic valve
repair in 142 patients'.\textsuperscript{2} We agree with their
statements and we will touch all their points and answer their questions
in this Reply.

We re-reviewed our database and had another in-depth analysis into the
data of our patients. According to Sievers classification of the
bicuspid aortic valve (BAV) all BAV's were Type 1 but one was Type 2 and
surprisingly, no single Type 1 was present. Due to some data issue, we
were no more able to elucidate the exact angle between the two
functional commissures anymore; however, giving this fact we can presume
the majority of the BAV's were asymmetric or very asymmetric with the
angle smaller than 180deg as described by Schafers et
al.\textsuperscript{3}

Considering the preoperative aortic annulus mean diameter was 27~+-
3.6~mm in the Group 1 (isolated BAV repair) and annuloplasty was
performed in only 20 patients (21\%; 10x subcommissural suture --
Cabrol, 9x partial external annuloplasty using a Dacron ring, and 1x
``basal'' suture annuloplasty -- Schafers) the need for cusp
augmentation is obvious. If no proper or none annuloplasty has been
performed a cusp augmentation, mostly of the fused cusp, using an
autologous pericardial patch, is mandatory to achieve sufficient
coaptation. The concept behind the augmentation was to achieve larger
effective orifice area, which is given by the nature smaller in BAV than
in tricuspid AV\textsuperscript{4} and consequently achieve lower
postoperative transvalvular gradients. As already mentioned in our
original article\textsuperscript{2} the pericardial patch augmentation
in our cohort seems to have a negative impact on BAV repair durability
as 92\% of patients in Group 1, who had to be reoperated on the AV or
had recurrent AR\selectlanguage{english}[?] 2deg in the follow\selectlanguage{english}-up, receive this technique. Similar
trend was observed in Group 2 (67\%). Due to this fact, we resigned from
this technique of BAV repair and do not use it anymore since 2018. In
our opinion, until an ``ideal'' patch material will be developed this
technique for BAV repair should definitely be abandoned. To delineate
this problematic, recently, we reoperated on one patient, who received
isolated BAV repair using autologous pericardial patch augmentation of
the fused (left/right) cusp 11 years ago. The intraoperative finding was
very interesting presenting extremely calcified BAV, especially the
fused cusp (Video 1). It looks actually as BAV which evolves originally
in AV stenosis, the more frequent pathological presentation of BAV. The
valve has been replaced with biological prosthesis and patient recovered
very well.

The preoperative diameter of the sino-tubular junction (STJ) of was
37.2~+-~9.1~mm in the Group of isolated BAV repair and STJ remodeling was
performed in only 12 (13\%; 6x ascending aortic replacement using a
Dacron prosthesis, and 6x PTFE felt strip annuloplasty). This is also
quite small number; however, in the case of using the pericardial patch
augmentation technique, sufficient coaptation of the BAV is reached
mainly through extraordinary high effective height of the cusps and
therefore STJ remodeling is not necessarily mandatory.

Our approach to the isolated repair of the BAV's has been changed and is
currently different than described above. Since we do not use
pericardial patch augmentation of the cusps anymore, we respect and
apply the principals of the current experts in this
field.\textsuperscript{5}

In conclusion, we have learned a lot over the years and were trying to
refine our BAV repair technique. In our opinion, by respecting the
above-mentioned principals, which are a consensus of the experts, we
believe, a very reasonable surgical option for the treatment of this
difficult congenital pathology can be offered to our patients. Finally,
indeed there is still a large room for improvement in long\selectlanguage{english}-term
durability of BAV repair and we should all keep on critical analyzing
our techniques and data.

We thank again Dr Jasinski et al. for their valuable insights.

With kind regards,

Tomas Holubec, Mojyan Safari, Arnaud Van Linden and Anton Moritz

\textbf{Acknowledgments and Disclosures}

\textbf{Funding statement:} none declared.

\textbf{Conflict of interest statement:} All authors declare they have
no conflict of interest.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Jasinski M, Kosiorowska K: Long-term durability of valve-sparing or
  repair procedures in BAV-Is there room for improvement? J Card Surg
  2022;37:1456.
\item
  Safari M, Monsefi N, Karimian-Tabrizi A, et al.: Longer-term outcomes
  after bicuspid aortic valve repair in 142 patients. J Card Surg
  2021;36:4645-4651.
\item
  Froede L, Schafers S, Wagenpfeil G, et al.: Simplified determination
  of commissural orientation in bicuspid aortic valves. Eur J
  Cardiothorac Surg 2020;58:1153-1160.
\item
  Marom G, Kim HS, Rosenfeld M, et al.: Fully coupled fluid-structure
  interaction model of congenital bicuspid aortic valves: effect of
  asymmetry on hemodynamics. Med Biol Eng Comput 2013;51:839-848.
\item
  Ehrlich T, de Kerchove L, Vojacek J, et al.: State-of-the art bicuspid
  aortic valve repair in 2020. Prog Cardiovasc Dis 2020;63:457-464.
\end{enumerate}

\textbf{Figure legends}

Video 1 Intraoperative video demonstrating the initially repaired
bicuspid aortic valve using autologous pericardial patch augmentation of
the fused cusp (Sievers type 1, left/right) before resection of the
valve. Picture-in-picture presenting intraoperative photograph of
resected heavily calcified aortic valve, stressed on the fused cusp.

\textbf{Hosted file}

\verb`BAV redo.mov`  available at \url{https://authorea.com/users/400229/articles/573094-reply-to-jasinski-m-et-al-indeed-there-is-still-room-for-improvement-in-long-term-durability-of-bav-repair}

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\end{document}

