Aortic valve repair using a differentiated surgical strategy

Introduction: Reconstruction of the aortic valve for pure regurgitation remains a surgical challenge because different mechanisms of cusp and root pathology can be involved in valve dysfunction. We have systematically tailored the repair to the individual pathology. We compared the results of aortic valve repair (AVR) in bicuspid and tricuspid valve anatomy.

Methods: Between 10/1995–6/2005, AVR was performed in 393 patients. A bicuspid aortic valve was seen in 137 patients (group A), a tricuspid aortic valve in 256 (group B). Root dilatation was corrected by subcommissural plication (A: 46; B: 70), supracommissural aortic replacement (A: 24; B: 31) and root remodeling (A: 70; B: 161). Cusp prolapse was corrected by plication of the free margin (A: 89; B: 139) or triangular resection (A: 60; B: 6), cusp defects were closed with a pericardial patch (A: 14; B: 24). Echocardiographic and clinical follow-up was on a yearly basis. Cumulative follow-up was 1129 patient-years (mean 2.9±2.1).

Results: Eleven patients died in hospital (2.8%; A: 2; B: 9). Twelve patients underwent reoperation for recurrent AR (A: 5; B: 7). Actuarial freedom from AR ≥ II at 5 years for bicuspid and tricuspid aortic valves was 91% and 89% (p=0.33). Actuarial freedom from AR ≥ II at 5 years was 81% for isolated valve repair and 95% for root replacement (p=0.29). Freedom from reoperation at 5 years was 94% anf 97% for bicuspid and tricupid aortic valves. No thromboembolic events occurred. There was 1 episode of endocarditis.

Conclusions: Aortic valve repair is feasible even for complex mechanisms of AR with a systematic and individually tailored approach. Valve stability of repaired bicuspid or tricuspid aortic valves are comparable.