Effects of Preoperative Aortic Insufficiency on Outcome After Aortic Valve–Sparing Surgery

Abstract

Background-The presence of significant preoperative aortic insufficiency (AI) or the need for cusp repair has been suggested as a risk factor for poorer outcomes after aortic valve (AV)-sparing surgery. We analyzed the influence of these factors on the mid-term outcomes of AV surgery. Methods and Results-Between 1996 and 2008, 164 consecutive patients underwent elective AV-sparing surgery. Severe preoperative AI (grade Ն3ϩ) was present in 93 patients (57%), and 54 (33%) had a bicuspid valve. Root repair was performed with either the reimplantation (74%) or the remodeling (26%) technique, and cusp repair was performed in 90 patients (55%). Mean clinical follow-up was 57 months. Hospital mortality was 0.6%. Cusp repair was required in 52% of the patients with preoperative AI Յ2ϩ and in 57% of those with AI Ն3ϩ (Pϭ0.6). Cusp repair was required more frequently in bicuspid versus tricuspid valves (91% versus 38%, PϽ0.001). Overall survival at 8 years was 88Ϯ8%. Freedom from AV reoperation at 8 years was similar with preoperative AI Յ2ϩ versus preoperative AI Ն3ϩ (89Ϯ11% versus 90Ϯ7%, Pϭ0.7) and with versus without cusp repair (84Ϯ17% versus 92Ϯ8%, Pϭ0.5). Freedom from recurrent AI (grade Ն3ϩ) at 5 years was also similar between groups (90Ϯ10% versus 89Ϯ8%, Pϭ0.9, and 90Ϯ8% versus 89Ϯ9%, Pϭ0.8, respectively). By multivariate analyses, predictors of recurrent AI Ն2ϩ were preoperative left ventricle end-diastolic diameter and AI Ͼ1ϩ on discharge echocardiography. Conclusions-With a systematic approach to cusp assessment and repair, AV-sparing surgery for root pathology has an acceptable mid-term outcome, irrespective of preoperative AI or need for cusp repair. (Circulation. 2009;120[suppl 1]: S120-S126.)

Feasibility and clinical outcome after minimally invasive valve-sparing aortic root replacement

“…If the valve cusps showed minor pathologies with basically good quality of tissue, then further cusp repair was performed, such as plication of the central portion [8] (Fig. 1C), elevation of the commissures or decalcification [9] (Fig. 1D).…”

Mid-Term Results of Valve-Sparing Aortic Root Replacement in Patients With Expanded Indications

“…This study investigated which clinical settings could influence outcomes in patients with expanded indication for VSRR in order to determine the populations who would benefit from this procedure. Points in controversies on indications for VSRR are different according to the reports in which needs of cusp repair [2], AAAD (3), inherited connective tissue disorder [12,13], cusp anomaly [14], or preoperative severe AR [15] particularly became a major focus. These reports demonstrated that each isolated indication came to favorable results that were equal to those of the control group.…”

Valve-sparing Aortic Root Replacement

“…The predictors of recurrent AR were preoperative left ventricle end-diastolic diameter and residual AR on discharge echocardiography. 40,41) These results might represent an earlier indication for VSRR and aggressive cusp repair if necessary. Svensson and colleagues used the CLASS (Commissure, Leaflet, Annulus, Sinuses, Sinotubular) evaluation for selecting the appropriate procedure and achieved excellent results after VSRR and concurrent cusp repair.…”

“…48) As reimplantation using the Valsalva graft confers the advantages of less cusp stress and secure annular fixation, the reoperation rate should be lower. 31,40) The level of cusp coaptation after reimplantation 44) and residual AR upon discharge 40,41) are possible predictors of recurrent AR. Whether VSRR combined with cusp repair is a risk factor for recurrent AR remains controversial.…”

“…Whether VSRR combined with cusp repair is a risk factor for recurrent AR remains controversial. [37][38][39][40][41] …”