Techniques of Autologous Pericardial Leaflet Replacement for Bicuspid Aortic Valve Endocarditis

Background and aim of the study: Valvular endocarditis constitutes high-risk cardiac surgery, with worse early and late results than for other disorders. Current data suggest that repairing endocarditis valves may produce better outcomes, but bicuspid endocarditis has been difficult to repair. Given the excellent early and late results now being achieved with autologous pericardial leaflet replacement, the present study involved complete pericardial leaflet replacement, a procedure that could facilitate the autologous reconstruction of bicuspid valves. Methods: Four patients with endocarditis of bicuspid valves, each exhibiting variations in anatomy and presentation, were included. All four patients had received antibiotics preoperatively and had been converted to culture-negative. All had infection of the fused leaflet, and three had retention of their normal non-fused leaflets for the repair. Using glutaraldehyde-fixed autologous pericardium, all damaged leaflets were fully replaced, employing bileaflet repairs in three patients and a trileaflet repair in one patient. One patient required both bicuspid leaflets to be replaced with two autologous pericardial leaflets because of concurrent calcification. Results: All four patients recovered uneventfully, and had fully competent valves with minimal gradients. All were subsequently managed without anticoagulation, and during up to two years of follow up the reconstructed valves functioned normally. None of the patients experienced any valve-related complications. Conclusion: In an anatomic spectrum of bicuspid endocarditis, the preservation of normal leaflets and complete replacement of damaged leaflets with autologous pericardium has provided an excellent reparative solution. This method could allow a stable autologous reconstruction in the majority of patients, although more experience and follow up will be necessary to fully validate the procedure.