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Ann Thorac Surg 2002;74:S1762-S1764
© 2002 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, University Hospitals Homburg, Homburg/Saar, Germany
* Address reprint requests to Dr Schäfers, Department of Thoracic and Cardiovascular Surgery, University Hospitals Homburg, Kirrberger Strasse, 66421 Homburg, Saar, Germany
e-mail: chhjsc{at}uniklinik-saarland.de
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: For aortic dilatation with morphologically intact leaflets, valve-preserving aortic replacement has become an accepted treatment modality. Leaflet prolapse, however, may be present, making composite replacement the most frequent choice. Alternatively, valve preservation may be combined with correction of leaflet prolapse. The results of this approach should be comparable with those of valve-preserving aortic surgery in the presence of normal leaflets.
METHODS: Between 1995 and 2002, 156 patients were treated by valve-preserving surgery. The aortic valve was bicuspid in 46, and tricuspid in 110 instances. In 88 aortic valves, apparently normal leaflet coaptation (normal, 12 bicuspid and 76 tricuspid), and in 68 instances, prolapse of one or more leaflets, was observed. Root remodeling (n = 133) or aortic replacement with valve reimplantation (n = 23) were performed. Leaflet prolapse was corrected by triangular resection (n = 16) or plicating sutures (n = 59), mostly placed in the central portion of the leaflet.
RESULTS: Neither operative mortality nor 5-year survival were influenced by the additional correction of prolapse. Freedom from reoperation at 1 year (normal, 98.8%; prolapse, 96.5%) and 5 years (normal, 97.3%; prolapse, 96.5%) were comparable in both cohorts, as was freedom from aortic regurgitation 
II at 1 year (normal, 98.8%; prolapse, 94.2%) and 5 years (94.4%).
CONCLUSIONS: Surgical correction of leaflet prolapse in combination with proximal aortic replacement is feasible with good results. Midterm results are identical with those known for morphologically normal leaflets. Repair of prolapse allows for preservation of the native valve in most patients with aortic regurgitation and aortic pathology, and thus appears a beneficial addition to valve-preserving surgery.
Within the past decade, valve-preserving aortic replacement has evolved into an increasingly accepted treatment modality for patients with proximal aortic disease and valve regurgitation [1, 2]. Good long-term results have been reported for the two principal operative techniques [3, 4], and other groups have adopted these approaches [5–8]. Despite growing enthusiasm for the principle, it is as yet unclear what proportion of patients can be treated by valve-preserving surgery, in particular because prolapse of one or more aortic valve leaflets has been considered an exclusion criterion for valve preservation.
Surgical correction of valve prolapse has become an option for isolated aortic regurgitation [9–12]. It can also be used in valve-preserving aortic replacement, and we hypothesized that it should result in adequate valve function through the combined effects of restoring root geometry and improving leaflet coaptation [13]. The question remains, however, whether the increased complexity is justified.
To be a therapeutic improvement, we felt that the applicability of valve-preserving surgery should be increased and the functional results made identical to those obtained with morphologically intact leaflets. We analyzed our current results in order to answer this question.
Patients and methods
Between 1995 and 2002, 156 patients were treated using valve-preserving surgery for aortic dilatation and aortic valve incompetence. Patient age ranged from 3 to 83 years (mean, 58 ± 15 years); 106 individuals were male. The underlying aortic pathology was chronic dissection in 7, acute dissection in 33, and aneurysm in 116 individuals. Aortic regurgitation ranged from grade II to grade IV, with a mean of 3.2.
Intraoperatively, the aortic valve was found to be bicuspid in 46 and tricuspid in 110 instances. Of all aortic valves, 88 had apparently normal leaflet coaptation (12 bicuspid, 76 tricuspid), with regurgitation apparently solely due to root dilatation. In 68 patients, prolapse of one (n = 53), two (n = 14), or three leaflets (n = 1) was observed (34 bicuspid, 34 tricuspid). Leaflet prolapse was defined as reduced height of the central portion of the respective leaflet of more than 3 mm compared with the remaining leaflet(s), with the commissures placed under radial tension. It was corrected by triangular resection (n = 16, all in bicuspid valves) or plicating sutures only (n = 59), mostly placed in the central portion (n = 51) of the leaflet [13].
Root remodeling (n = 133) or aortic replacement with valve reimplantation (n = 23) were performed as determined by individual aortic root dimensions [13]. Concomitant procedures (coronary artery bypass, n = 28; mitral reconstruction, n = 11; arch replacement, n = 97) were added as required by the individual pathology.
All patients were studied intraoperatively by transesophageal echocardiography and followed postoperatively at regular intervals by transthoracic echocardiography. The degree of aortic regurgitation was determined in semiquantitative fashion [14].
The results were analyzed retrospectively with the patients divided into two groups, one with normal leaflets (Norm) and one with relevant leaflet prolapse (Prol). Data are expressed as mean ± standard deviation. Parametric and continuous variables were compared using contingency tables and the Mann-Whitney U test. Kaplan-Meier estimates of freedom from reoperation and increased degree of aortic regurgitation were calculated (Prism; GraphPad Inc., San Diego, CA).
Results
There were only a few differences between the two groups with respect to age, gender, concomitant cardiac disease, type of aortic disease, arch extension, or myocardial ischemic time (Table 1).
Operative mortality (Norm, 4.5%; Prol, 2.9%) and 5-year survival were similar in both cohorts. No patient experienced an adverse event such as thromboembolism or hemorrhage. Four patients required reoperation for recurrent regurgitation. Freedom from reoperation at 1 year (Norm, 98.8%; Prol, 96.5%) and 5 years (Norm, 97.3%; Prol, 96.5%) was not significantly different. Freedom from aortic regurgitation II at 1 year (Norm, 98.8%; Prol, 94.2%) and 5 years (94.4%) was comparable in both cohorts (Fig 1);
freedom from regurgitation I at 5 years was slightly, but insignificantly (p = 0.387) better after prolapse repair (Fig 2).
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Valve-preserving aortic replacement has been shown to be an excellent option for patients with aortic valve regurgitation and proximal aortic aneurysm [1–4]. Apart from eliminating the risks of thromboembolism and anticoagulation-related hemorrhage associated with composite replacement, the function of the preserved aortic valve is physiologic [15]. The two principal operative techniques, however, were originally designed for patients with morphologically normal valve leaflets, in whom regurgitation is due to dilatation of the aortic root [1, 2]. This implies that valve preservation may not be appropriate in patients in whom a combination of root dilatation and leaflet prolapse is present, and is thus limited in its applicability.
Whereas good results have initially been reported for valve-preserving surgery, not all valves have retained their function [3–6]. The exact cause of repair failure has not always been analyzed in detail. Basically, either dilatation at the aortoventricular level (in root remodeling) or valve prolapse remain as the possible causes. Few observations are available to judge the relative role of secondary aortoventricular dilatation [7]. Over-reduction of sinutubular diameter has been associated with recurrent regurgitation [6], probably through alteration of the relationship between root and valve dimensions and the generation of valve prolapse [16]. Generalized postoperative leaflet prolapse (as defined by the coaptation line) has also been proposed as the most important risk factor for valve failure in another series [5]. Isolated leaflet prolapse was additionally found at reoperation in the first two failures of this series [8]. These observations underlie the hypothesis that restoration of near-perfect root geometry and leaflet coaptation is an important prerequisite for stable long-term function [13]. This concept is similar to the established principles of mitral reconstruction, in which both leaflet prolapse and ring dilatation should be corrected for long-term valve competence [10]
We have previously shown that the addition of leaflet prolapse repair to root replacement does not result in increased morbidity or hospital mortality [13]. With increasing experience, this has not changed. Despite applying leaflet repair to more pronounced valve pathology in recent years, freedom from significant regurgitation and reoperation at 1 year has remained at more than 95%, essentially identical to the results with those valves that were thought to be morphologically intact at the time of operation. Most importantly, we have not seen deterioration of valve function between 1 and 5 years postoperatively, unlike the results with valves thought to be intact in this series and others [3–8]. Almost all valves have maintained their function regardless of the type of root replacement, anatomy of the aortic valve, or the addition of leaflet repair. These results are encouraging despite the fact that only a limited number of patients have reached 5-year follow-up, and no 10-year data are yet available.
The optimal technique of leaflet repair is still open to controversy. Trusler and associates suggested shortening of the leaflet margin close to the commissures for correction of isolated prolapse [9]. We have used this technique and abandoned it because of the occurrence of secondary valve failure, particularly in combination with ventricular septal defect closure. Carpentier proposed triangular excision of redundant leaflet tissue with reapproximation of the remaining parts [10]. In our experience, this has been difficult because it requires a high level of judgment as to how much leaflet tissue to excise. The use of several plicating sutures on the central portion of the free leaflet margin allows a more stepwise length reduction. Depending upon the actual configuration, sutures may be added or removed easily.
On the basis of the current experience, correction of valve prolapse appears a very reasonable extension of the original techniques of valve-preserving surgery. Despite seemingly unfavorable preoperative leaflet morphology, postoperative valve function has remained identical to that obtained in morphologically intact leaflets. It has allowed us to extend the use of valve preservation to more than 80% of patients with aortic regurgitation and aortic dilatation without incurring an increased risk of morbidity or mortality.
References
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