Simulation-guided outlet valve repair: early integration of computationally-derived principles of free-edge length in bicuspidization repair

Background Symmetric bicuspidization repair for outlet valve pathologies relies on the surgeon's subjective assessment. Recent computational and ex-vivo work suggests sizing free-edge length to 1.57 times aortic diameter is optimal. This principle was applied clinically at our institution, and this study compares post-implementation outcomes with historical results. Methods All patients with attempted bicuspidization from 2011 to 2025 were queried. Primary outcome was freedom from valve-related reoperation or valve replacement. Secondary outcomes were cross-clamp time, number of bypass runs, mean transvalvular gradient, and regurgitation grade. Kaplan–Meier curves were generated for primary outcome with log-rank comparison. Secondary outcomes were compared with Wilcoxon rank-sum test. Results At median age 5.9 years, fourteen patients underwent symmetric bicuspidization (9 historical, 5 simulation-guided). Valve configuration included unicuspid ( n = 2), bicuspid ( n = 6), tricuspid ( n = 4), and quadricuspid ( n = 2). Repair indication was predominantly regurgitation ( n = 13/14, 93%). Five (56%) historical patients underwent reoperation compared with zero simulation-guided patients (median follow-up 948 vs. 455 days). Three (33%) historical patients required repeat bypass run, compared to zero simulation-guided. Cross-clamp time was not different between groups (72 vs. 89, p = 0.74). Acute and latest postoperative mean gradients were also not significantly different (acute: 13.5 vs. 9.6, p = 0.14; latest: 12.4 vs. 3.3, p = 0.08), though gradient variability was two to four times lower in the simulation-guided group. Conclusions This exploratory study presents promising early outcomes after prespecified, standardized sizing of the free-edge length in symmetric bicuspidization repair. Simulation-guided design can be applied in complex valve repair and may enhance early outcomes.