Is small cusp size a limitation for aortic valve repair?†

Abstract

OBJECTIVES We sought to investigate cusp size limitations for valve repair in patients with aortic regurgitation (AR). METHODS Preoperative computed tomography was performed in 105 patients. Cusp geometric height (GH) and annulus size were measured. Mean patient age was 60.7 ± 13.7 years. Mean GH of 3 cusps was used in the analysis. Annulus cusp mismatch was graded using predicted coaptation length. Patients were categorized by mean GH into group S (GH <16 mm; n = 35) or L (GH ≥16 mm; n = 70). RESULTS Preoperative mean GH was 17.1 ± 2.3 mm. GH and body height were significantly correlated (r = 0.61). Intraoperative mean GH (18.8 ± 2.2 mm) was larger than preoperative mean GH (P < 0.0001). However, postoperative (17.1 ± 2.0 mm) and preoperative mean GH did not differ. Moderate AR was not present on predischarge echocardiography. Mild AR was observed in 51% and 17% of patients in groups S and L, respectively (P = 0.006). During follow-up, moderate or severe AR was observed in 14% and 10% of patients in groups S and L, respectively (P = 0.74). Two patients in group S required reoperation for a regurgitant valve. Twenty (83%) and 15 (21%) patients in groups S and L, respectively, had severe annulus cusp mismatch before surgery. Annulus cusp mismatch resolved in most patients in group L postoperatively, whereas more than half the patients in group S still had severe mismatch. CONCLUSIONS Small cusp size (GH <16 mm) is not necessarily a contraindication in aortic valve repair. However, most patients in this group had annulus cusp mismatch. Root replacement or secure annulus plication is mandatory to correct annulus cusp mismatch.

Normative Aortic Valvar Measurements in Adults Using Cardiac Computed Tomography ― A Potential Guide to Further Sophisticate Aortic Valve-Sparing Surgery ―

“…Dimensions of the virtual basal ring and the sinuses of Valsalva varied between the various modalities and method- especially for the geometric height. 32 Komiya et al demonstrated that the intraoperative measurement value of geometric height was, on average, 1.7 mm larger than the preoperative computed tomographic measurement. 32 This small difference matters because the precise measurement of the leaflet size represented by the geometric height is important to avoid aortic root-leaflet mismatch (relative shortage of geometric height leading to a coaptation length <2 mm) to secure appropriate coaptation.…”

“…32 This small difference matters because the precise measurement of the leaflet size represented by the geometric height is important to avoid aortic root-leaflet mismatch (relative shortage of geometric height leading to a coaptation length <2 mm) to secure appropriate coaptation. 32 Overestimation of leaflet size has a risk to trigger insufficient annuloplasty, which leads to residual aortic regurgitation due to inappropriate coaptation.…”

“…This discrepancy may reflect that the clinical goal of the aortic valve-sparing surgery is not simply restoring normal anatomy but optimizing the physiological function of the aortic valve with some safety margin. 32 Even applying a 4-6 mm safety margin to ensure sufficient coaptation, this is narrower than that of the mitral valve. Consequently, aortic valve-sparing surgery requires experience, expertise, and more sophisticated tools, 32 which makes the standardization of this procedure difficult.…”

The 10 Commandments for Aortic Valve Repair

“…In effect, geometric height is probably the most important parameter when determining postrepair root dimensions, such as annulus or ST junction. 39 Effective height is the only quantitative parameter for cusp configuration; its normal value is 9 to 19 mm or 45% of geometric height in TAV. 8,40 It can be determined by echocardiography as well as intraoperatively with a caliper (MSS-1, Fehling Instruments, Karlstein, Germany).…”

“…In effect, geometric height is probably the most important parameter when determining postrepair root dimensions, such as annulus or ST junction. 39…”