Aortic valve repair for aortic insufficiency in adults: a contemporary review and comparison with replacement techniques

Quadricuspid aortic valve (QAV) is a rare congenital anomaly often associated with aortic insufficiency. The exact anatomy of QAV is variable, and most cases have undergone aortic valve replacement. With the recognition that aortic valve repair achieves superior patient outcomes as compared to replacement, a systematic approach to autologous reconstruction of QAV is needed. This article reports 2 cases having successful repair utilizing geometric aortic annuloplasty rings, and describes a proposed scheme for repairing most QAV defects, based on relative leaflet and commissural characteristics. Using either tri-leaflet or bicuspid ring annuloplasty, the normal sub-commissural triangles can be remodeled into a 120° or 180° configuration, respectively, and then the leaflets can be sutured and plicated to fit annular geometry. With this approach, most quadricuspid valves potentially could undergo autologous reconstruction.

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Predictors of Recurrent Aortic Insufficiency in Type I Bicuspid Aortic Valve Repair

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2018.06.026 ◽

2018 ◽

Vol 106 (5) ◽

pp. 1316-1324 ◽

Cited By ~ 9

Author(s):

Andreas Habertheuer ◽

Rita Karianna Milewski ◽

Joseph E. Bavaria ◽

Mary Siki ◽

Melanie Freas ◽

...

Keyword(s):

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Type I ◽

Valve Repair

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Aortic valve repair with a newly approved geometric annuloplasty ring in patients undergoing proximal aortic repair: early results from a single-centre experience

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa009 ◽

2020 ◽

Vol 57 (6) ◽

pp. 1137-1144

Author(s):

Oliver K Jawitz ◽

Vignesh Raman ◽

Jatin Anand ◽

Muath Bishawi ◽

Soraya L Voigt ◽

...

Keyword(s):

Aortic Valve ◽

Transoesophageal Echocardiography ◽

Aortic Disease ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Valve Repair ◽

Annuloplasty Ring ◽

Aortic Repair ◽

Early Results

Abstract OBJECTIVES Aortic insufficiency (AI) is common in patients with proximal aortic disease, but limited options exist to facilitate aortic valve repair (AVr) in this population. This study reports ‘real-world’ early results of AVr using newly FDA-approved trileaflet and bicuspid geometric annuloplasty rings for patients with AI undergoing proximal aortic repair (PAR) in a single referral centre. METHODS All patients undergoing AVr with a rigid internal geometric annuloplasty ring (n = 47) in conjunction with PAR (ascending +/− root +/− arch) were included. Thirty-six patients underwent AVr with a trileaflet ring, and 11 patients underwent AVr with a bicuspid ring. The rings were implanted in the subannular position, and concomitant leaflet repair was performed if required for cusp prolapse identified after ring placement. RESULTS The median age was 58 years [interquartile range (IQR) 46–70]. PAR included supracoronary ascending replacement in 26 (55%) patients and remodelling valve-sparing root replacement with selective sinus replacement in 20 (42%) patients. Arch replacement was performed in 38 (81%) patients, including hemi-arch in 34 patients and total arch in 4 patients. There was no 30-day/in-hospital mortality. Preoperative AI was 3–4+ in 37 (79%) patients. Forty-one (87%) patients had zero–trace AI on post-repair transoesophageal echocardiography, and 6 patients had 1+ AI. The median early post-repair mean gradient was 13 mmHg (IQR 5–20). Follow-up imaging was available in 32 (68%) patients at a median of 11 months (IQR 10–13) postsurgery. AI was ≤1+ in 97% of patients with 2+ AI in 1 patient. All patients were alive and free from aortic valve reintervention at last follow-up. CONCLUSIONS Early results with geometric rigid internal ring annuloplasty for AVr in patients undergoing PAR appear promising and allow a standardized approach to repair with annular diameter reduction and cusp plication when needed. Longer-term follow-up will be required to ensure the durability of the procedure.

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Aortic Valve Repair for Aortic Insufficiency or Dilatation: Technical Evolution and Long-term Outcomes

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2020.03.105 ◽

2020 ◽

Vol 110 (6) ◽

pp. 1967-1973 ◽

Cited By ~ 1

Author(s):

Razan Salem ◽

Andreas Zierer ◽

Afsaneh Karimian-Tabrizi ◽

Aleksandra Miskovic ◽

Anton Moritz ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Valve Repair ◽

Long Term Outcomes

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Predictors of Aortic Valve Repair Failure

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/1556984519845905 ◽

2019 ◽

Vol 14 (3) ◽

pp. 199-208 ◽

Cited By ~ 1

Author(s):

Bobby Yanagawa ◽

Amine Mazine ◽

Ismail El-Hamamsy

Keyword(s):

Aortic Valve ◽

Three Dimensional ◽

Major Complication ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Valve Repair ◽

Current State ◽

Annular Dilation

Aortic valve repair is the preferred approach for the treatment of severe aortic insufficiency (AI), as it allows patients to keep their native aortic valve, thus substantially reducing the risk of prosthesis-related complications. Several studies have documented excellent long-term outcomes of aortic valve repair. The major complication of this operation is AI recurrence, with ensuingneed for reoperation. The surgical experience accumulated over the last two decades has allowed for better understanding of the mechanisms of recurrent AI after aortic valve repair. Herein, we review the current state of knowledge on predictors of aortic valve repair failure. These include unaddressed annular dilation, residual cusp prolapse or retraction, commissural orientation, and use of patch material. This enhanced understanding has led to the development of increasingly refined techniques and improved patient outcomes. Continued follow-up and detailed data collection at the time of surgery, together with three-dimensional echo imaging, will allow further improvements in aortic valve repair.

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Clinical and Echocardiographic Outcomes After Aortic Valve Repair Surgery

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/1556984519845657 ◽

2019 ◽

Vol 14 (3) ◽

pp. 209-217 ◽

Cited By ~ 1

Author(s):

Eilon Ram ◽

Boris Orlov ◽

Ami Shinfeld ◽

Alexander Kogan ◽

Leonid Sternik ◽

...

Keyword(s):

Aortic Valve ◽

Clinical Outcomes ◽

Multivariable Analysis ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Pericardial Patch ◽

Valve Repair ◽

Significant Independent Predictor ◽

Autologous Pericardial Patch

Objective To assess early and late clinical outcomes in patients who underwent aortic valve repair surgery for aortic valve insufficiency, and to investigate predictors for recurrence. Methods Of 151 consecutive patients who underwent aortic valve repair surgery for varying degrees of aortic insufficiency (AI) in our department between 2004 and 2018, 60 (40%) underwent aortic root replacement, 71 (47%) aortic cusp plication, 31 (20%) subcommissural annuloplasty, 29 (19%) circular annuloplasty, and 28 (18%) autologous pericardial patch augmentation. Results One patient died in the hospital (0.7%). Mean clinical and echocardiographic follow-up was 62±43 months (range 1 to 159) and 50 ± 40 months (range 1 to 158), respectively. The overall survival rate was 99.3% at 1 year and 98% at 5 years of follow-up. Seventeen patients (11.3%) had recurrent severe AI, and all of them underwent reoperation with a mean duration to reoperation of 35 ± 39 months. Risk factors for the development of recurrent significant AI (≥3) or reoperation, by univariable analysis, were unicuspid or bicuspid aortic valve (AV) ( P = 0.018), the use of subcommissural annuloplasty ( P = 0.010), the need for cusp repair ( P = 0.001), and the use of pericardial patch augmentation ( P < 0.001). By multivariable analysis only the use of pericardial patch augmentation emerged as a significant independent predictor for the development of recurrent significant AI (≥3) or reoperation ( P = 0.020). Conclusion AV repair can be performed with low morbidity and mortality, with good early and late clinical outcomes. However, in our experience there was a significant rate of recurrent AI especially in patients who underwent cusp augmentation using glutaraldehyde-treated autologous pericardial patch.

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Transcatheter aortic valve repair for management of aortic insufficiency in patients supported with left ventricular assist devices

Journal of Cardiac Surgery ◽

10.1111/jocs.12814 ◽

2016 ◽

Vol 31 (10) ◽

pp. 654-657 ◽

Cited By ~ 3

Author(s):

Jay D. Pal ◽

James M. McCabe ◽

Todd Dardas ◽

Gabriel S. Aldea ◽

Nahush A. Mokadam

Keyword(s):

Aortic Valve ◽

Aortic Insufficiency ◽

Left Ventricular ◽

Ventricular Assist Devices ◽

Aortic Valve Repair ◽

Left Ventricular Assist Devices ◽

Valve Repair ◽

Ventricular Assist ◽

Transcatheter Aortic Valve ◽

Left Ventricular Assist

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Techniques of Aortic Valve Repair

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e31824641d7 ◽

2011 ◽

Vol 6 (6) ◽

pp. 348-354 ◽

Cited By ~ 10

Author(s):

J. Scott Rankin ◽

Jeffrey G. Gaca

Keyword(s):

Aortic Valve ◽

Aortic Root ◽

Free Edge ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Valve Repair ◽

Aortic Valves ◽

Mitral Repair ◽

Cavitron Ultrasonic Surgical Aspirator ◽

Valve Reconstruction

Similar to mitral repair, newer methods of aortic valve reconstruction are achieving excellent outcomes with an 85% to 90% freedom from valve-related complications at 10 years. The goal of this review is to illustrate these newer and more stable techniques of aortic valve repair. Most patients with aortic insufficiency from either trileaflet or bicuspid aortic valves are candidates for repair, in addition to selected patients with mixed aortic stenosis/insufficiency and aortic root aneurysms. Initially, aggressive commissural annuloplasty is performed to reduce measured valve diameter to 19 to 21 mm. Leaflet prolapse is corrected with plication stitches placed in the free edge of each leaflet adjacent to the Nodulus Arantius. In this regard, the leaflet free edge functions as the chorda tendinea of the aortic valve, and shortening with plication stitches raises the leaflet to a proper “effective height.” Leaflet defects are augmented with gluteraldehyde-fixed autologous pericardium, and mild-to-moderate strategically placed spicules of calcium are removed with the cavitron ultrasonic surgical aspirator. Using these methods, most insufficient aortic valves, and many with mixed lesions, can be satisfactorily repaired. Six cases are illustrated in this review, spanning the spectrum of pathologies from annular dilatation without leaflet defects, to standard congenital bicuspid valve with prolapse, to trileaflet prolapse, to unusual bicuspid pathology with calcification, to a moderately calcified trileaflet valve with mixed lesions, and to aortic root aneurysms with severe aortic insufficiency. All valves were repaired using the techniques described above with trivial residual leak and minimal gradients. All repairs have been followed with yearly echocardiography, and valve reconstruction with these methods is now quite stable with excellent late outcomes. Most insufficient aortic valves now can undergo stable repair with minimal late valve-related complications. Greater application of aortic valve repair seems indicated.

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