Repair of trileaflet aortic valve prolapse: mid-term outcome in patients with normal aortic root morphology
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《血管的通路杂志》
a Department of Thoracic and Cardiovascular Surgery, Saint Luc Hospital, Université Catholique de Louvain, avenue Hippocrate 10, 1200 Brussels, Belgium
b Department of Cardiology, Saint Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
c Department of Thoracic and Cardiovascular Surgery, Saint Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
Presented at the joint 20th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 14th Annual Meeting of the European Society of Thoracic Surgeons, Stockholm, Sweden, September 10–13, 2006.
Abstract
We described our mid-term results in repairing prolapsing aortic cusps in 21 patients with aortic regurgitation and normal aortic root morphology. Aortic regurgitation was moderate–severe in five patients and severe in 16 patients. Prolapse involved the left cusp in four patients (19%), the right cusp in 10 patients (47%) and the non-coronary cusp in 7 (33%) patients. Correction of the prolapsing cusp was achieved by either free edge plication, triangular resection or resuspension with polytetrafluoroethylene sutures, frequently associated to a subcommissural annuloplasty. There was no hospital death. At discharge transthoracic echocardiography, 18 patients (85%) showed no residual aortic regurgitation and three patients (14%) had trivial aortic regurgitation with a central jet. Mean clinical follow-up was 27.2±17.1 months (range: 10–72 months). Overall survival was 90.5%. At follow-up transthoracic echocardiography, fourteen patients (73%) were free from aortic regurgitation and five patients (26%) had mild aortic regurgitation without clinical signs of congestive heart failure. Correction of valve prolapse appears a reasonable extension of the original techniques of valve-preserving surgery.
Key Words: Aortic valve repair; Valve disease
1. Introduction
Isolated prolapse of one or more aortic cusps is a frequent cause of regurgitation. While aortic valve repair for dilated annulus is the most accepted indication, some controversy exists about aortic valve repair for patients with bicuspid aortic valve (BAV) and cusp prolapse of trileaflet valves. This controversy stems from the concern for an increased need for reoperation in these patients. The Toronto group reported a 26% reoperation rate at five years in their series of 54 adults with congenital heart disease both with and without BAV [1]. Surgeons at the Cleveland Clinic reported a 13% reoperation rate in a series of 94 BAV patients [2]. Thanks to a better understanding of the underlying pathophysiology and recent improvements in surgical techniques, isolated leaflet prolapse without concomitant aortic root dilatation is applicable to valve reconstruction, with encouraging results [2–5]. In the present study, we investigated whether the systematic surgical correction of aortic cusp prolapses, without additional aortic root pathology, allow a good surgical outcome and durability of the repair.
2. Materials and methods
Between 1998 and 2005, we treated 90 patients for aortic regurgitation: 69 had a BAV; 21 patients with isolated cusp prolapse of a tricuspid aortic valve and a normal root morphology underwent valve repair. Patients age ranged from 28 to 77 years (mean: 59.5±13 years); 19 individuals were male. Preoperative transesophageal echocardiography showed the mean ejection fraction of the left ventricle (LVEF) was 59±12% (range: 27–72%), the mean end-diastolic diameter of the left ventricle (LVEDD) was 61.3±10.7 mm (range: 46–92 mm) and the mean left ventricular mass index was 165.6±68.9 g/m2 (range: 82–371 g/m2). Aortic regurgitation was moderate–severe in five patients and severe in 16 patients (Fig. 1). Prolapse involved the left cusp in four patients (19%), the right cusp in 10 patients (47%) and the non-coronary cusp in 7 (33%) patients. Cusp free edge plication was performed in 13 (61%) patients, the cusp free edge resection was chosen in four patients (19%), six patients (28%) underwent cusp free edge reinforcement with a CV 7 polytetrafluoroethylene running suture. In one patient (5%) the shaving of the cusp edge was performed, three patients (14%) had the cusp decalcification and in two patients (9%) a pericardial patch was used to reconstruct the cusp. In addition, 17 patients (80%) underwent subcommissural annuloplasty and sinotubular junction plication was performed in six patients (28%). Mean cardiopulmonary bypass time was 102.4± 36.5 min (range: 54–167 min) and mean aortic cross-clamp time was 79.7±29.9 min (range: 34–136 min). Concomitant surgical procedures were: coronary artery bypass graft in five patients, resection of a myxoma in one patient and mitral valve plasty in three patients. Clinical and echocardiographic follow-up was performed in all patients (100% complete).
2.1. Operative techniques
After induction of anaesthesia, all patients were studied intraoperatively by transesophageal echocardiography: true cusp prolapse was considered to be present whenever the free margin of the cusp was below the level of its parietal insertion. The quality of the cusp tissue, the level of coaptation, the presence of a prolapse and the anatomy of the aortic root were assessed. Colour Doppler was used to analyse the direction of the regurgitant jet within the left ventricular outflow tract – the presence of a ventral jet indicates that the level of cusp coaptation is symmetrical. By contrast, eccentric jets are typically associated with asymmetrical cusp coaptation due to the presence of either a true or a relative prolapse of one or more aortic cusps. After transverse aortotomy, three prolene 4/0 (Ethicon Inc., MA, USA) sutures were passed through the three commissures. The correction of relative prolapses due to unequal length of one or more cusps was achieved by using either a double radial plication of the area of excess tissue or by a single central plication by a 6/0 running suture, depending on the quality of the cusp tissue and the degree of prolapse. In patients with poor tissue quality and in whom suture plication was not possible, a triangular resection was performed. If coaptation was still inadequate or below the annular level, free edge reinforcement was applied. Subcommissural annuloplasty was performed using pledgeted Ethibond 2/0 (Ethicon Inc., MA, USA) at the level of the interleaflets triangle close to the base we used this to stabilize the aortic root and increase the area of cusp coaptation. Free margin reinforcement was performed with Goretex CV-7 (Gore W.L., Gore and Associates, Flagstaff, AZ). For this purpose, an over and over running suture was performed on each cusp while radial and vertical tensions were, respectively, exercised on the three commissures and the three margins. By exerting a gradual tension on the suture, it was possible to bring the free-cusp margins to the appropriate level, improve coaptation and correct any residual prolapse. The aim of this procedure is not only to reinforce the free margins of the cusps but also to support the other techniques used for correction of the cusp prolapse and hence, produce a more durable repair. Plasty of the sino-tubular junction was performed using pledgeted prolene 4/0 placed at the middle part of the intercommissural segment, taking particular care to avoid any overreduction which could distort the geometry of the aortic root. Surgical techniques are shown in Fig. 2. After the aorta was unclamped and haemodynamic conditions had returned back to normal, TEE was repeated. Any eccentric jet or aortic regurgitation >1 prompted further correction.
2.2. Statistical analysis
All data were reviewed retrospectively. The analysis was performed with the SPSS software 13.0 (SPSS Inc, Chicago, IL). Continuous variables were expressed as mean±S.D., categorical data as percentages. Wilcoxon's signed rank test was used for comparison of the variables.
3. Results
Two patients (9.6%) needed early reoperation because of bleeding. Hospital morbidity included complete A-V block in two patients (9%), atrial fibrillation in four patients (19%) and pneumonia in one patient (4%). There was no hospital death. Mean postoperative ICU stay was 1.8± 0.9 days (1–4 days) and the mean hospital stay was 12.5±5.6 days (range: 7–30 days). At discharge transthoracic echocardiography, 18 patients (85%) showed no residual aortic regurgitation and three patients (14%) had trivial aortic regurgitation with a central jet. Mean clinical follow-up was 27.2±17.1 months (range: 10–72 months). There were two deaths during follow-up: one patient died from lung cancer and one patient died from acute aortic dissection. All patients were in NYHA class I or II. At follow-up transthoracic echocardiography, fourteen patients (73%) were free from aortic regurgitation and five patients (26%) had mild aortic regurgitation without clinical signs of congestive heart failure. The mean postoperative LVEF was 61.3%±10.2% and the mean left ventricular mass index was 158.7±64.2 g/m2. Statistical analysis showed a statistically significant improvement of the LVEDD postoperatively (P=0.007): 61.3±10.7 mm (range: 46–92 mm) vs. 52.8± 8.1 mm (range: 42–77 mm) (Fig. 3).
4. Discussion
Aortic cusp prolapse is a frequent cause of aortic regurgitation. It can either be isolated (post-inflammatory, degenerative, idiopathic, infections, traumatic) or associated with abnormalities of the aortic root and/or ascending aorta morphology. Once installed, chronic aortic regurgitation can contribute to further damage cusp structure. Turbulence from the high velocity regurgitant jet indeed results in the thickening of the free margin of the cusp while the increased stress imposed on the cusps is responsible for the fragilization of the commissural areas and the appearance of fenestration which may ultimately rupture. Aortic valve reconstruction techniques have gained increasing interest within recent years not only because of the absence of risks of thromboembolism and anticoagulation related hemorrhage but also because of the more physiologic function of the preserved aortic valve. Different techniques have been proposed with different results: initial techniques for correction of aortic cusp prolapse have been described by Fruter and Trusler in the specific indication of the syndrome of ventricular septal defect with aortic insufficiency caused by a prolapsed aortic cusp [6,7]. Then, Carpentier [9] and Duran [5] reported excellent early results in patients whom prolapse aetiology was mainly rheumatic or congenital in origin [10]. Long-term results have been also reported by Casselman et al. [2] and Cosgrove [4] in bicuspid aortic valves with excellent intermediate results. Bicuspid valve anatomy in particular appears to facilitate leaflet reconstruction because only a single coaptation line has to be appreciated in contrast to the more complex interference of three coaptation lines in tricuspid valves [11]. In these studies repair failure, whenever occurring, was attributed to either progression of the underlying disease, recurrence of the cusp prolapse, dilation of the aorto-ventricular and sino-tubular junctions or inadequate surgical techniques. Since currently there are no data about the outcome of repair procedures to treat patients with an isolated prolapse of a tricuspid aortic valve, we sought to investigate whether the prolapse can be repaired by using surgical techniques that restore cusp coaptation. Careful surgical inspection, together with a detailed preoperative TEE analysis, enabled us to identify cusp prolapse in a significant number of patients with isolated aortic regurgitation. It also allowed us to determine which cusp was involved and whether we were dealing with a true or a relative cusp prolapse. To make this difference, we defined an adequate reference point to which the actual level of cusp coaptation could be compared: when only one cusp was prolapsing, the other two cusps were the reference level; when all three cusps were prolapsing, we usually considered that the optimum height for coaptation should be the middle distance of the height of the commissure. Because maximum leaflet shear stress is close to the commissures, we never used commissural resuspensions or plication near the commissure because of the fragile nature of the tissue at this level and the presence of associated fenestrations. Unfortunately, correction of the free margin length by itself was frequently not sufficient to cure the prolapse. Indeed, at the end of this procedure, many patients (81%) still demonstrate a rather small coaptation area. Subcommissural annuloplasty helped us to increase the coaptation area. We combined it with a free edge reinforcement with a polytetrafluoroethylene running suture to heighten the shortened cusp in six patients (28%), in order to further stabilize the more fragile segments of the valve and reduce the incidence of prolapse recurrence. The functional results of cusp repair procedures documented by echocardiography were encouraging: 14 patients (73%) were free from aortic regurgitation at follow-up and five patients (26%) had mild aortic regurgitation without clinical signs of congestive heart failure. We share the hypothesis that an important risk factor for recurrent regurgitation is the overreduction of sinotubular diameter, probably through alteration of the relationship between root and valve dimensions and the generation of valve prolapse [12–14]. Correction of valve prolapse appears a very reasonable extension of the original techniques of valve-preserving surgery. Systematic detection of cusp prolapse and the application of appropriate corrective techniques seem to improve mid-term surgical results, even if further observations will be necessary to judge the long-term fate of the leaflet prolapse repair.
Conference discussion
Dr. K. Khargi (The Hague, Netherlands): Your group is a front runner on reconstruction of aortic valves. You have four levels that you actually correct, that is, the cusp, the annulus, sinus of Valsalva and the sinotubular junction. Although, apparently, the sinotubular junction was normal, you still performed a sinotubular remodeling with these plication sutures. Why
Dr. Chiappini: Yes, because if you look at the international literature, for example, from the results from the Mayo Clinic, from the Cleveland Clinic, from the Toronto group, you can see that the reoperation is due mainly to the lack of coaptation of the leaflets, it could be results of the surgical technique, but usually if you perform transthoracic echocardiography, you can say that it depends on the subsequent dilatation of the aortic junction or the sinotubular junction. Therefore, we believe that it is an additional maneuver. You can take it in a couple of minutes with only three stitches at the middle part of the intercommissural segment at the level of the sinotubular junction. So this maneuver, this very easy maneuver at that time of the first operation is very useful at long-term.
Dr. Khargi: So it stabilizes it
Dr. Chiappini: Yes.
Dr. Khargi: You had three patients with an immediate trivial aortic regurgitation postoperatively. How do these patients relate to the five patients during late follow-up, which you observed Were these patients the same, who deteriorated in mild regurgitations or were these other patients
Dr. Chiappini: Yes, they were the same, the same patients followed during the time.
Dr. Khargi: But if you have this observation, is that a sign that the patients are deteriorating gradually or is it your interpretation of stability
Dr. Chiappini: At this moment they are stable.
Dr. Khargi: So you consider them stable
Dr. Chiappini: Yes.
Dr. H. Imadi (Damascus, Syria): I want to ask, do you obtain intraoperatively echo, whether it is transesophageal or thoracic, before
Dr. Chiappini: Yes, of course. Our usual monitoring system in the intraoperative is, via the anesthesiologist, transesophageal echocardiography. We perform it at the beginning of the operation to evaluate better the mechanism of valve prolapse, of valve incompetence, in order to establish the right surgical strategy, and then we check usually the surgical results by the transesophageal echocardiography.
Dr. Imadi: So these three cases you decided intraoperatively to do this
Dr. Chiappini: Yes, because they were 1+ regurgitation, and when they are 1+ our policy is to stay and do it.
References
Rao V, Van Arsdell GS, David TE, Azakie A, Williams WG. Aortic valve repair for adult congenital heart disease: a 22-year experience. Circulation 2000; 102:III40–43.
Casselman FP, Gillinov AM, Akhrass R, Kasirajan V, Blackstone EH, Cosgrove DM. Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet. Eur J Cardio-Thorac Surg 1999; 15:302–308.
Sam Haydar H, He GW, Hovaguimian H, McUrvin D, King D, Starr A. Valve repair for aortic insufficiency: surgical classification and techniques. J Cardiothorac Surg 1997; 11:258–265.
Cosgrove DM, Rosenkranz ER, Hendren WG, Bartlett JC, Stewart WJ. Valvuloplasty for aortic insufficiency. J Thorac Cardiovasc Surg 1991; 102:571–577.
Duran C. Aortic valve repair and reconstruction. Open Tech Card Thorac Surg 1996; 1:15–29.
Frater RW. The prolapsing aortic cusp. Experimental and clinical observations. Ann Thorac Surg 1967; 3:63–67.
Trusler GA, Williams WG, Smallhorn JF, Freedom RM. Late results after repair of aortic insufficiency associated with ventricular septal defect. J Thorac Cardiovasc Surg 1992; 103:276–281.
El Khoury G, Vanoverschelde JL, Glineur D, Poncelet A, Verhelst R, Astarci P, Underwood MJ, Noirhomme Ph. Repair of aortic valve prolapse: experience with 44 patients. Eur J Cardio-thorac Surg 2004; 26:628–633.
Carpentier A. Cardiac valve surgery: the French correction. Thorac Cardiovasc Surg 1983; 86:323–337.
Okita Y, Miki S, Kusuhara K, Ueda Y, Tahata T, Yamanaka K, Shiraishi S, Tamura T, Tatsuta N, Koie H. Long-term results of aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect. J Thorac Cardiovasc Surg 1988; 96:769–774.
Langer F, Graeter T, Nikoloudakis N, Aicher D, Wendler O, Schfers HJ. Valve-preserving aortic replacement: Does the additional repair of leaflet prolapse adversely affect the results J Thorac Cardiovasc Surg 2001; 122:270–277.
Bassano C, De Paulis R, Penta de Peppo AP, Tondo A, Fratticci L, De Matteis GM, Ricci A, Sommaria L, Chiariello L. Residual aortic valve regurgitation after aortic root remodeling without a direct annuloplasty. Ann Thorac Surg 1998; 66:1269–1272.
Kunzelman KS, Grande J, David TE, Cochran RP, Verrier ED. Aortic root and valve relationships. J Thorac Cardiovasc Surg 1994; 107:162–170.
Schfers HJ, Aicher D, Langer F. Correction of leaflet prolapse in valve-preserving aortic replacement: pushing the limits Ann Thorac Surg 2002; 74:S1762–1764.(Bruno Chiappini, Anne-Catherine Pouleur,)
b Department of Cardiology, Saint Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
c Department of Thoracic and Cardiovascular Surgery, Saint Luc Hospital, Université Catholique de Louvain, Brussels, Belgium
Presented at the joint 20th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 14th Annual Meeting of the European Society of Thoracic Surgeons, Stockholm, Sweden, September 10–13, 2006.
Abstract
We described our mid-term results in repairing prolapsing aortic cusps in 21 patients with aortic regurgitation and normal aortic root morphology. Aortic regurgitation was moderate–severe in five patients and severe in 16 patients. Prolapse involved the left cusp in four patients (19%), the right cusp in 10 patients (47%) and the non-coronary cusp in 7 (33%) patients. Correction of the prolapsing cusp was achieved by either free edge plication, triangular resection or resuspension with polytetrafluoroethylene sutures, frequently associated to a subcommissural annuloplasty. There was no hospital death. At discharge transthoracic echocardiography, 18 patients (85%) showed no residual aortic regurgitation and three patients (14%) had trivial aortic regurgitation with a central jet. Mean clinical follow-up was 27.2±17.1 months (range: 10–72 months). Overall survival was 90.5%. At follow-up transthoracic echocardiography, fourteen patients (73%) were free from aortic regurgitation and five patients (26%) had mild aortic regurgitation without clinical signs of congestive heart failure. Correction of valve prolapse appears a reasonable extension of the original techniques of valve-preserving surgery.
Key Words: Aortic valve repair; Valve disease
1. Introduction
Isolated prolapse of one or more aortic cusps is a frequent cause of regurgitation. While aortic valve repair for dilated annulus is the most accepted indication, some controversy exists about aortic valve repair for patients with bicuspid aortic valve (BAV) and cusp prolapse of trileaflet valves. This controversy stems from the concern for an increased need for reoperation in these patients. The Toronto group reported a 26% reoperation rate at five years in their series of 54 adults with congenital heart disease both with and without BAV [1]. Surgeons at the Cleveland Clinic reported a 13% reoperation rate in a series of 94 BAV patients [2]. Thanks to a better understanding of the underlying pathophysiology and recent improvements in surgical techniques, isolated leaflet prolapse without concomitant aortic root dilatation is applicable to valve reconstruction, with encouraging results [2–5]. In the present study, we investigated whether the systematic surgical correction of aortic cusp prolapses, without additional aortic root pathology, allow a good surgical outcome and durability of the repair.
2. Materials and methods
Between 1998 and 2005, we treated 90 patients for aortic regurgitation: 69 had a BAV; 21 patients with isolated cusp prolapse of a tricuspid aortic valve and a normal root morphology underwent valve repair. Patients age ranged from 28 to 77 years (mean: 59.5±13 years); 19 individuals were male. Preoperative transesophageal echocardiography showed the mean ejection fraction of the left ventricle (LVEF) was 59±12% (range: 27–72%), the mean end-diastolic diameter of the left ventricle (LVEDD) was 61.3±10.7 mm (range: 46–92 mm) and the mean left ventricular mass index was 165.6±68.9 g/m2 (range: 82–371 g/m2). Aortic regurgitation was moderate–severe in five patients and severe in 16 patients (Fig. 1). Prolapse involved the left cusp in four patients (19%), the right cusp in 10 patients (47%) and the non-coronary cusp in 7 (33%) patients. Cusp free edge plication was performed in 13 (61%) patients, the cusp free edge resection was chosen in four patients (19%), six patients (28%) underwent cusp free edge reinforcement with a CV 7 polytetrafluoroethylene running suture. In one patient (5%) the shaving of the cusp edge was performed, three patients (14%) had the cusp decalcification and in two patients (9%) a pericardial patch was used to reconstruct the cusp. In addition, 17 patients (80%) underwent subcommissural annuloplasty and sinotubular junction plication was performed in six patients (28%). Mean cardiopulmonary bypass time was 102.4± 36.5 min (range: 54–167 min) and mean aortic cross-clamp time was 79.7±29.9 min (range: 34–136 min). Concomitant surgical procedures were: coronary artery bypass graft in five patients, resection of a myxoma in one patient and mitral valve plasty in three patients. Clinical and echocardiographic follow-up was performed in all patients (100% complete).
2.1. Operative techniques
After induction of anaesthesia, all patients were studied intraoperatively by transesophageal echocardiography: true cusp prolapse was considered to be present whenever the free margin of the cusp was below the level of its parietal insertion. The quality of the cusp tissue, the level of coaptation, the presence of a prolapse and the anatomy of the aortic root were assessed. Colour Doppler was used to analyse the direction of the regurgitant jet within the left ventricular outflow tract – the presence of a ventral jet indicates that the level of cusp coaptation is symmetrical. By contrast, eccentric jets are typically associated with asymmetrical cusp coaptation due to the presence of either a true or a relative prolapse of one or more aortic cusps. After transverse aortotomy, three prolene 4/0 (Ethicon Inc., MA, USA) sutures were passed through the three commissures. The correction of relative prolapses due to unequal length of one or more cusps was achieved by using either a double radial plication of the area of excess tissue or by a single central plication by a 6/0 running suture, depending on the quality of the cusp tissue and the degree of prolapse. In patients with poor tissue quality and in whom suture plication was not possible, a triangular resection was performed. If coaptation was still inadequate or below the annular level, free edge reinforcement was applied. Subcommissural annuloplasty was performed using pledgeted Ethibond 2/0 (Ethicon Inc., MA, USA) at the level of the interleaflets triangle close to the base we used this to stabilize the aortic root and increase the area of cusp coaptation. Free margin reinforcement was performed with Goretex CV-7 (Gore W.L., Gore and Associates, Flagstaff, AZ). For this purpose, an over and over running suture was performed on each cusp while radial and vertical tensions were, respectively, exercised on the three commissures and the three margins. By exerting a gradual tension on the suture, it was possible to bring the free-cusp margins to the appropriate level, improve coaptation and correct any residual prolapse. The aim of this procedure is not only to reinforce the free margins of the cusps but also to support the other techniques used for correction of the cusp prolapse and hence, produce a more durable repair. Plasty of the sino-tubular junction was performed using pledgeted prolene 4/0 placed at the middle part of the intercommissural segment, taking particular care to avoid any overreduction which could distort the geometry of the aortic root. Surgical techniques are shown in Fig. 2. After the aorta was unclamped and haemodynamic conditions had returned back to normal, TEE was repeated. Any eccentric jet or aortic regurgitation >1 prompted further correction.
2.2. Statistical analysis
All data were reviewed retrospectively. The analysis was performed with the SPSS software 13.0 (SPSS Inc, Chicago, IL). Continuous variables were expressed as mean±S.D., categorical data as percentages. Wilcoxon's signed rank test was used for comparison of the variables.
3. Results
Two patients (9.6%) needed early reoperation because of bleeding. Hospital morbidity included complete A-V block in two patients (9%), atrial fibrillation in four patients (19%) and pneumonia in one patient (4%). There was no hospital death. Mean postoperative ICU stay was 1.8± 0.9 days (1–4 days) and the mean hospital stay was 12.5±5.6 days (range: 7–30 days). At discharge transthoracic echocardiography, 18 patients (85%) showed no residual aortic regurgitation and three patients (14%) had trivial aortic regurgitation with a central jet. Mean clinical follow-up was 27.2±17.1 months (range: 10–72 months). There were two deaths during follow-up: one patient died from lung cancer and one patient died from acute aortic dissection. All patients were in NYHA class I or II. At follow-up transthoracic echocardiography, fourteen patients (73%) were free from aortic regurgitation and five patients (26%) had mild aortic regurgitation without clinical signs of congestive heart failure. The mean postoperative LVEF was 61.3%±10.2% and the mean left ventricular mass index was 158.7±64.2 g/m2. Statistical analysis showed a statistically significant improvement of the LVEDD postoperatively (P=0.007): 61.3±10.7 mm (range: 46–92 mm) vs. 52.8± 8.1 mm (range: 42–77 mm) (Fig. 3).
4. Discussion
Aortic cusp prolapse is a frequent cause of aortic regurgitation. It can either be isolated (post-inflammatory, degenerative, idiopathic, infections, traumatic) or associated with abnormalities of the aortic root and/or ascending aorta morphology. Once installed, chronic aortic regurgitation can contribute to further damage cusp structure. Turbulence from the high velocity regurgitant jet indeed results in the thickening of the free margin of the cusp while the increased stress imposed on the cusps is responsible for the fragilization of the commissural areas and the appearance of fenestration which may ultimately rupture. Aortic valve reconstruction techniques have gained increasing interest within recent years not only because of the absence of risks of thromboembolism and anticoagulation related hemorrhage but also because of the more physiologic function of the preserved aortic valve. Different techniques have been proposed with different results: initial techniques for correction of aortic cusp prolapse have been described by Fruter and Trusler in the specific indication of the syndrome of ventricular septal defect with aortic insufficiency caused by a prolapsed aortic cusp [6,7]. Then, Carpentier [9] and Duran [5] reported excellent early results in patients whom prolapse aetiology was mainly rheumatic or congenital in origin [10]. Long-term results have been also reported by Casselman et al. [2] and Cosgrove [4] in bicuspid aortic valves with excellent intermediate results. Bicuspid valve anatomy in particular appears to facilitate leaflet reconstruction because only a single coaptation line has to be appreciated in contrast to the more complex interference of three coaptation lines in tricuspid valves [11]. In these studies repair failure, whenever occurring, was attributed to either progression of the underlying disease, recurrence of the cusp prolapse, dilation of the aorto-ventricular and sino-tubular junctions or inadequate surgical techniques. Since currently there are no data about the outcome of repair procedures to treat patients with an isolated prolapse of a tricuspid aortic valve, we sought to investigate whether the prolapse can be repaired by using surgical techniques that restore cusp coaptation. Careful surgical inspection, together with a detailed preoperative TEE analysis, enabled us to identify cusp prolapse in a significant number of patients with isolated aortic regurgitation. It also allowed us to determine which cusp was involved and whether we were dealing with a true or a relative cusp prolapse. To make this difference, we defined an adequate reference point to which the actual level of cusp coaptation could be compared: when only one cusp was prolapsing, the other two cusps were the reference level; when all three cusps were prolapsing, we usually considered that the optimum height for coaptation should be the middle distance of the height of the commissure. Because maximum leaflet shear stress is close to the commissures, we never used commissural resuspensions or plication near the commissure because of the fragile nature of the tissue at this level and the presence of associated fenestrations. Unfortunately, correction of the free margin length by itself was frequently not sufficient to cure the prolapse. Indeed, at the end of this procedure, many patients (81%) still demonstrate a rather small coaptation area. Subcommissural annuloplasty helped us to increase the coaptation area. We combined it with a free edge reinforcement with a polytetrafluoroethylene running suture to heighten the shortened cusp in six patients (28%), in order to further stabilize the more fragile segments of the valve and reduce the incidence of prolapse recurrence. The functional results of cusp repair procedures documented by echocardiography were encouraging: 14 patients (73%) were free from aortic regurgitation at follow-up and five patients (26%) had mild aortic regurgitation without clinical signs of congestive heart failure. We share the hypothesis that an important risk factor for recurrent regurgitation is the overreduction of sinotubular diameter, probably through alteration of the relationship between root and valve dimensions and the generation of valve prolapse [12–14]. Correction of valve prolapse appears a very reasonable extension of the original techniques of valve-preserving surgery. Systematic detection of cusp prolapse and the application of appropriate corrective techniques seem to improve mid-term surgical results, even if further observations will be necessary to judge the long-term fate of the leaflet prolapse repair.
Conference discussion
Dr. K. Khargi (The Hague, Netherlands): Your group is a front runner on reconstruction of aortic valves. You have four levels that you actually correct, that is, the cusp, the annulus, sinus of Valsalva and the sinotubular junction. Although, apparently, the sinotubular junction was normal, you still performed a sinotubular remodeling with these plication sutures. Why
Dr. Chiappini: Yes, because if you look at the international literature, for example, from the results from the Mayo Clinic, from the Cleveland Clinic, from the Toronto group, you can see that the reoperation is due mainly to the lack of coaptation of the leaflets, it could be results of the surgical technique, but usually if you perform transthoracic echocardiography, you can say that it depends on the subsequent dilatation of the aortic junction or the sinotubular junction. Therefore, we believe that it is an additional maneuver. You can take it in a couple of minutes with only three stitches at the middle part of the intercommissural segment at the level of the sinotubular junction. So this maneuver, this very easy maneuver at that time of the first operation is very useful at long-term.
Dr. Khargi: So it stabilizes it
Dr. Chiappini: Yes.
Dr. Khargi: You had three patients with an immediate trivial aortic regurgitation postoperatively. How do these patients relate to the five patients during late follow-up, which you observed Were these patients the same, who deteriorated in mild regurgitations or were these other patients
Dr. Chiappini: Yes, they were the same, the same patients followed during the time.
Dr. Khargi: But if you have this observation, is that a sign that the patients are deteriorating gradually or is it your interpretation of stability
Dr. Chiappini: At this moment they are stable.
Dr. Khargi: So you consider them stable
Dr. Chiappini: Yes.
Dr. H. Imadi (Damascus, Syria): I want to ask, do you obtain intraoperatively echo, whether it is transesophageal or thoracic, before
Dr. Chiappini: Yes, of course. Our usual monitoring system in the intraoperative is, via the anesthesiologist, transesophageal echocardiography. We perform it at the beginning of the operation to evaluate better the mechanism of valve prolapse, of valve incompetence, in order to establish the right surgical strategy, and then we check usually the surgical results by the transesophageal echocardiography.
Dr. Imadi: So these three cases you decided intraoperatively to do this
Dr. Chiappini: Yes, because they were 1+ regurgitation, and when they are 1+ our policy is to stay and do it.
References
Rao V, Van Arsdell GS, David TE, Azakie A, Williams WG. Aortic valve repair for adult congenital heart disease: a 22-year experience. Circulation 2000; 102:III40–43.
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