Two decades of valve-sparing root reimplantation in tricuspid aortic valve: impact of aortic regurgitation and cusp repair

Abstract

OBJECTIVES Our goal was to analyse the influence of preoperative aortic regurgitation (AR) on the necessity of cusp repair during valve-sparing reimplantation (VSR). We focused on patients with tricuspid aortic valves (TAV) and evaluated the impact of AR and cusp repair on long-term outcomes. METHODS From March 1998 to December 2018, a total of 512 consecutive patients underwent VSR at our institution; of these, 303 had a TAV. The mean age was 53 ± 15 years, and the median follow-up was 6.12 years. The rate and type of cusp repair were analysed based on preoperative AR. Time-to-event analysis was performed, as well as risk of death, reoperation and AR recurrence. RESULTS Cusp repair was necessary in 168 (55.4%) patients; the rate rose significantly as AR grade increased (P < 0.001). In-hospital mortality was 1% (n = 3). At 5 and 10 years, overall survival was 92 ± 2% and 75 ± 5%, respectively. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR >2+ and AR >1+ at 10 years was 88 ± 4% and 70.4 ± 4.6%, respectively. Independent predictors of death included age, New York Heart Association functional class and type-A aortic dissection. Predictors of AR greater than mild included previous cardiac surgery and severe preoperative AR. CONCLUSION In patients with TAV receiving VSR, the necessity of cusp repair increased with the degree of preoperative AR. Preoperative AR and cusp repair do not impact long-term survival and aortic valve reoperation, but severe preoperative AR and multiple cusp repair increase the risk of recurrent moderate-to-severe AR. Overall, cusp repair seems to attenuate the negative impact of preoperative AR for at least 1 decade in a majority of patients.

Early Outcomes of Patients Undergoing Neoaortic Valve Repair Incorporating Geometric Ring Annuloplasty

“…43 Each of these approaches has been utilized in similar patients, but stable autologous valve repair may be superior to any of the prosthetic valve replacement strategies. Potential advantages of geometric ring annuloplasty over repair with external annular stabilization 43 include a more precise definition of annuloplasty size based on leaflet FEL and establishment of normal elliptical valve geometry. The external annuloplasty approach does not specifically account for leaflet size and assigns an arbitrary diameter to the annulus; whereas the geometric ring affords a predictable and standardized leaflet/annulus match, specifically tailored to the patient's anatomy.…”

“…Alternative management techniques include valve-sparing root replacement, 4,28,42 mechanical valve replacement, 4 homograft root replacement, 4,5 bioprosthetic valve replacement, 4 and external reimplantation annuloplasty. 43 Each of these approaches has been utilized in similar patients, but stable autologous valve repair may be superior to any of the prosthetic valve replacement strategies. Potential advantages of geometric ring annuloplasty over repair with external annular stabilization 43 include a more precise definition of annuloplasty size based on leaflet FEL and establishment of normal elliptical valve geometry.…”

Commentary: Aortic regurgitation and aortic cusp repair: The devil is in the details

“…Aortic valve repair techniques have evolved over the past few years. Techniques such as aortic cusp repair, annular and sinotubular junction stabilization, and aortic valve reimplantation have been shown to be safe and effective, 1 , 2 and they avoid the potential drawbacks associated with aortic valve replacement.…”

“…The average severity of aortic regurgitation is increasing, and the frequency of the need for cusp repair is increasing with it. 2 In this issue of the Journal , Zhu and Woo 3 provide an excellent and comprehensive review of cusp-repair techniques for bicuspid and tricuspid aortic valves. The authors describe a range of techniques from free margin plication to complex triangular resection with pericardial reconstruction, in which experience and expertise are key to achieving satisfactory results.…”

“…Multiple cusp repairs and preoperative regurgitation can increase the risk of a nondurable repair. 2 For all these various techniques, experience is required to achieve excellent leaflet hemodynamics and a long-lasting functional aortic valve.…”