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a Division of Cardiothoracic and Vascular Surgery, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
b Division of Anesthesiology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
c Division of Cardiology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
Accepted for publication April 16, 2009.
* Address correspondence to Dr de Kerchove, Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, Brussels, 1200, Belgium (Email: laurent.dekerchove{at}uclouvain.be).
Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
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Abstract |
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Methods: Between 1996 and 2008, 376 patients underwent elective AV repair: 88 with trileaflet AV (23%) had cusp prolapse repair, plication technique was performed in 34 (39%), resuspension technique in 33 (37%) and plication plus resuspension in 21 (24%). One cusp was repaired in 55 (62%), 2 cusps in 18 (21%), and 3 cusps in 15 (17%).
Results: No hospital deaths occurred. Patients undergoing resuspension with or without plication had more preoperative aortic insufficiency (AI; p = 0.01) and multiple cusp prolapses (p = 0.01). During follow-up (median, 41 months), 4 deaths occurred and 2 were cardiac related. Overall survival at 5 years was 95% ± 5%. Two patients needed AV reoperation because of recurrent AI or AI plus AV stenosis. Recurrent AI grade 
3+ developed in 4 patients; 1 with moderate AV stenosis. Freedom from reoperation at 5 years was 100% for plication, 96% ± 4% for resuspension, and 93% ± 7% for plication plus resuspension (p = 0.6); respective freedom from AI 3+ at 3 years was 100%, 92% ± 8%, and 89% ± 11% (p = 0.8).
Conclusions: Cusp plication or resuspension are efficient and durable techniques to correct cusp prolapse in the trileaflet AV. Plication is typically the first choice because of its ease of use and lower risk of overcorrection; however, free margin resuspension is useful in specific situations.
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Introduction |
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In the tricuspid AV, cusp prolapse is generally caused by a distension of the free margin, which ends its course in systole below the coaptation area compared with the other cusps. The surgical techniques described to correct cusp prolapse attempt to shorten the cusp free margin, thereby elevating the cusp and its level of coaptation. The most commonly described techniques are plication and triangular resection. Plication techniques have been described by several authors on the paracommissural zone [5, 6] or on the central portion of the free margin [7].
Triangular resection is generally used when fibrosis or calcification of the prolapsing cusp is present and is therefore used primarily in the setting of a bicuspid valve raphe, with or without the use of a pericardial patch to repair the defect [8, 9]. Another technique to repair cusp prolapse is the free margin resuspension using a polytetrafluoroethylene (PTFE) suture. This technique was initially described by David and colleagues [10] to reinforce the free margin of the cusp in patients undergoing valve-sparing root replacement. Our group has adapted the technique to treat cusp prolapse [11].
In this study we analyze the midterm outcomes after prolapse repair using free margin plication or resuspension techniques, or both. The end points analyzed were survival, need for AV reoperation, and the recurrence of significant AI (3+) at follow-up. We also sought to determine risk factors for the AI recurrence after surgical repair.
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Material and Methods |
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Patients
From January 1996 to September 2008, 376 consecutive patients underwent elective AV repair at a single center. In this population, 250 patients (67%) had a tricuspid AV, 122 (32%) had a bicuspid AV, and 4 (1%) had quadricuspid AV. Data on valve repair techniques were collected prospectively and reviewed retrospectively. From this database we identified 88 patients (23%) with a trileaflet AV who underwent repair of cusp prolapse. The choice of the technique was determined at the surgeon's discretion. Patients undergoing root or ascending aorta replacement, or other concomitant cardiac procedures, were included.
Surgical Technique
AI was assessed preoperatively by transthoracic (TTE) echocardiography, complemented by transesophageal echocardiography (TEE) or a computed tomography (CT) scan of the aorta in case of dilatation. Intraoperatively, TEE was systematically performed before and after cardiopulmonary bypass. Severity of AI was classified according to 4 grades using semiquantitative criteria. Cusp prolapse was diagnosed echocardiographically on the basis of the presence of an eccentric regurgitant jet. Eccentricity was defined as a jet axis not parallel to outflow tract axis, with the direction of the jet indicating location of the prolapse [12]. Because a central jet can also be seen in case of symmetric prolapse of all cusps, it was not considered as an exclusion criteria for the determination of cusp prolapse.
The surgical approach of AV insufficiency and proximal aorta pathology was guided by "Repair Oriented Functional Classification of AI" developed at our center and previously described [13]. Definition and assessment of aortic cusp prolapse as well as the techniques of prolapse repair have been previously described [14]. Briefly, cusp prolapse was identified when the cusp free margin was lower compared with adjacent cusps or when all free margins were at a similar level but below the normal AV coaptation level (middle height of the commissures). In the trileaflet AV, cusp prolapse was repaired using the plication or resuspension techniques, or both.
The plication technique was performed with a 5-0 or 6-0 Prolene suture (Ethicon Inc, Hamburg, Germany) placed in the central portion of the free margin and extended perpendicularly from the free margin, about 4 to 5 mm through the belly of the leaflet to decrease cusp belly distension and respect its natural nest shape. If the prolapse was severe, the excess tissue excluded by the plication was resected to avoid cusp restriction.
The resuspension technique was performed using a 7-0 Gore-Tex suture (W. L. Gore and Associates, Flagstaff, AZ) passed in running fashion over and over along the entire length of the free margin. Free margin shortening was obtained by applying tension on both Gore-Tex suture arms, which were locked when appropriate correction was reached.
The two techniques were introduced since the beginning of the study period. In the trileaflet AV, both techniques are feasible on any cusp prolapse; however, several situations can influence the surgeon's choice. The resuspension technique was preferentially used to close fenestrations and reinforce a fragile free margin. Resuspension was also preferred to plication in cases of symmetric prolapse of all 3 leaflets (low coaptation) that can occur after root replacement. Finally, resuspension was added to plication in some patients to accentuate the prolapse repair or to reinforce the free margin, or both.
In the absence of root replacement, subcommissural annuloplasty was performed almost systematically along with the prolapse repair. Subcommissural annuloplasty consists of a Teflon (DuPont, Wilmington, DE) reinforced U stitches at the level of each intercommissural triangle. Prolapse repair in patients who needed root replacement was usually performed after reimplantation of the AV into the graft.
Follow-Up
Clinical follow-up was conducted through outpatient visits or telephone interview by a research nurse. In addition to survival status, information on valve-related complications, including thromboembolism, hemorrhage, endocarditis, reoperation, and cardiovascular symptoms, was obtained whenever possible. All patients underwent TTE at discharge and then at regular intervals during the course of the follow-up. Echocardiograms that were not obtained at our institution were interpreted by the referring physician.
Statistical Analysis
Data are presented as mean ± standard derivation for continuous data or as number (%) for categoric variables. Continuous variables were compared using the t test for normally distributed variables and the Wilcoxon rank sum test for nonnormally distributed variables. Categoric variables were compared using the 
2 test. Failure time data for survival, reoperation, and recurrent AI 3+ are presented using Kaplan-Meier survival curves. Univariate comparisons between groups for failure time data were performed using the log-rank test. Results were considered statistically significant at the level of p 
0.05. Statistical analyses were performed using SAS 9.1 software (SAS Institute, Carey, NC). Graphs were constructed with Prism 4.0 software (GraphPad Software Inc, San Diego, CA).
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Echocardiographic Results
TTE follow-up was available in 83 patients (94%) after a median of 25 months (range, 1 to 107 months). Table 3 reports the severity of residual or recurrent AI in the three groups at operation, discharge, and follow-up. At 3 years, freedom from AI 3+ was 94% ± 6% (Table 2), with no significant difference between the 3 groups (plication, 100%; resuspension, 92% ± 8%; plication plus resuspension, 89 ± 11%; p = 0.8).
By univariate analysis, the predictors of recurrent AI 3+ were preoperative left ventricular end-diastolic dilatation (diameter > 65 mm; p = 0.002) and multiple-cusp prolapse repair (p = 0.04). Multivariate analyses were not performed because of the low number of outcome events.
At discharge, TTE showed a peak gradient of less than 20 mm Hg in 82 patients, between 20 and 30 mm Hg in 6, and exceeded 30 mm Hg in 1. At follow-up echocardiography in 83 patients, peak gradient was less than 20 mm Hg in 76, between 20 and 30 mm Hg in 5, and exceeded 30 mm Hg in 2 (Table 4). Both patients with gradients exceeding 30 mm Hg had plication plus resuspension. One of those 2 patients had a gradient exceeding 30 mm Hg since discharge, which remained stable over time, and the other patient presented with a gradient increase associated with AI and required reoperation.
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Comment |
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In this study, we analyzed and compared the results of two different techniques used to repair cusp prolapse in the trileaflet AV. The results show that central plication of the free margin and resuspension of the free margin with Gore-Tex suture are both efficient and reproducible techniques to repair cusp prolapse. The midterm results are good and similar for both techniques. In certain cases, resuspension can be added to plication with similar midterm results compared with either technique used alone. A left ventricular end-diastolic diameter exceeding 60 mm and multiple-cusp prolapse repair were identified as predictors of recurrent AI 3+.
Correction of AV cusp prolapse represents a balance between undercorrection, thereby leaving residual prolapse, and overcorrection causing cusp restriction and contributing to valve stenosis. Schafers and colleagues [15] have suggested that residual prolapse with eccentric AI after repair is commonly associated with reoperation. Central plication of the free margin plication is a quick and efficient technique for prolapse correction. It leaves minimal foreign material on the cusp and causes very localized thickening of the free margin in a zone that is naturally thickened (nodulus Arantii). When performed centrally, the plication is part of the coaptation area, a zone that is exposed to a lower stress compared with the paracommissural zone as shown by finite element analysis [16]. Consistent with other series [15], we observed excellent results, with no reoperation and only one recurrence of severe AI.
Free margin resuspension was initially described by David and colleagues [10] to reinforce the aortic cusps with stress fenestrations in patients having valve-sparing root replacement. Since the 1996, we have adopted this technique and extended its use to treat cusp prolapse in tricuspid and in bicuspid AV [9, 11]. The advantages of this technique include the reinforcement of the free margin and that it can be added to other techniques such as plication or triangular resection [14]. Disadvantages include that it leaves more foreign material on the cusp compared with the plication technique. However, the experience with artificial chordae in mitral valve repair has shown an excellent biocompatibility of the Gore-Tex suture [17], and valve restriction due to fibrous reaction or calcification is extremely rare [18].
The 5-year freedom from reoperation and 3-year freedom from AI 3+ in this study were, respectively, 96% and 92% for resuspension and 93% and 89% for plication plus resuspension. These results may be confounded by the presence of more severe preoperative AI in the resuspension groups and the preferred use of PTFE in the setting of multiple-cusps prolapse. There are limited reports of the use of the resuspension technique to correct aortic cusp prolapse. In the report by David and colleagues, resuspension was used in 22% of patient undergoing AV-sparing procedures. Although the 10-year freedom from reoperation and freedom from moderate or severe AI were 95% and 85%, respectively, the outcomes for the subgroup of patients receiving resuspension were not reported [2]. In a feasibility study, Fattouch and colleagues [19] reported no AI recurrence at 1 year in 26 patients who had a modified resuspension technique.
In our evolving approach to AV repair, we have adopted clear diagnostic criteria for cusp prolapse based on objective anatomic references. In isolated cusp prolapse, the free margins of the adjacent normal cusp are taken as reference. In multiple-cusp prolapse, the midheight of the sinuses of Valsalva is the reference for the coaptation level of the cusps. We have also developed a systematic procedure for both the plication and resuspension techniques that estimates and corrects the excess of free margin length [14].
During the study period, our criteria for acceptable results after the repair have become more stringent. Our goal is to have a competent valve with a coaptation level 5 to 8 mm higher than the plane of the nadir of the cusp insertion. We have demonstrated that short coaptation length (<4 mm) and low coaptation level are two important echocardiographic predictors of repair failure [20]. Furthermore, any eccentric AI, suggesting a residual prolapse, mandates reexploration of the AV. Only mild central AI jets are accepted after repair because of their favorable prognosis over time.
Free margin plication has become our technique of choice to treat trileaflet AV prolapse. This technique is simple and applicable in the setting of thin and pliable cusp tissue as is usually the case in trileaflet AVs. In bicuspid AVs, plication is also preferred for cusps with thin and pliable tissue. The resuspension technique is useful to close stress fenestrations that are suspected to cause residual AI. These fenestrations usually are located along the free margin on the coaptation surface. In bicuspid AVs, resuspension can reinforce and homogenize the cusp free margin after triangular resection with or without a pericardial patch [14]. When resuspension is added to another technique, care must been taken to avoid overcorrection.
This study is a retrospective and nonrandomized comparison of two techniques for cusp prolapse repair and represents a decade of evolving experience with AV repair. As such, any inferences drawn from this data are limited by confounding variables such as number of repaired cusps and severity of preoperative AI that are differently distributed between study groups. Our sample size also limits our ability to perform extensive statistical adjustments for these differences. Last, a more thorough echocardiographic evaluation of the presence, magnitude, eccentricity, and origin of AI jets at follow-up may give further insight into the stability of the different cusp repair techniques over time.
In conclusion, central plication of the free margin and free margin resuspension with Gore-Tex suture are two techniques of cusp prolapse repair in the trileaflet AV. Our study confirms that both techniques can reproducibly and effectively correct cusp prolapse and provide similar midterm clinical and echocardiographic results. Preoperative left ventricular dilation and multiple cusp prolapses are important risk factors for recurrent AI. In certain cases, resuspension may be added to plication to accentuate the prolapse repair without compromising the midterm outcome.
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Discussion |
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First, your median follow-up is only 3.5 years and only about 15% of your patients have follow-up beyond 5 years. The Carr and Savage meta-analysis of aortic valve repair that appeared in 2004 in the European Journal of Cardiothoracic Surgery showed that repair and replacement have very similar outcomes out to 5 years but diverge thereafter, with repair having significantly higher reoperation rates. Therefore, we must be very cautious about conclusions of the durability of these repairs or the equivalence of the repair techniques with only early to midterm follow-up.
Second, the use of plication vs PTFE suspension was at the surgeon's discretion, and presumably, one technique was chosen over another for good reason. That similar results were achieved with the two techniques may speak mainly to good surgical decision making rather than comparable efficiency of the two techniques. Perhaps you could discuss the choice of these techniques and provide us with some guidelines. I myself am very reluctant to use PTFE suspension on thin leaflets that are often seen in young patients with connective tissue disorders and aortic aneurysms.
Third, because aortic bioprostheses are so reliable and durable in the elderly, how do you decide between valve repair and replacement in patients above age 70 or 75?
Finally—and I apologize for asking this because I suspect there is no easy answer—how much is too much residual aortic regurgitation after repair and how do you decide when to replace the leaking repaired aortic valve?
Again, I congratulate the authors and I thank the Society for the privilege of discussing this paper. Thank you.
DR De KERCHOVE: Thank you for those kind remarks and interesting questions. Of course, no definitive conclusion can be made on basis of midterm follow-up. We are, like you are, very interested in the long-term follow-up of these patients who are all followed very closely.
To answer to your first question about the indications of the different techniques, I would say that the plication technique became our first choice because of its simplicity. Central plication is applicable in any thin and pliable cusp, which is usually the case in the trileaflet aortic valve. The PTFE technique remains a useful technique to close stress fenestration on the coaptation area, and personally we don't fear to use the PTFE to reinforce a very thin and fragile free margin, as we have never experienced a tear after repairing those kind of cusp with this technique.
To answer your second question about our approach in patients older than 70 years, first I would say that those patients represent 21% of this cohort and that thus far none of them has experienced recurrence of severe aortic regurgitation. Although we do not contraindicate valve repair in those patients; however, we are very exigent on the quality of their valve, which must be free of fibrosis or calcification. Moreover, the repair of an isolated cusp prolapse can be very easily and rapidly performed; if we don't have a perfect result on intraoperative echocardiographic control, we do not hesitate to change the valve.
Concerning your third question about the results we require after aortic valve repair, we become more and more severe in regard to the residual regurgitation and actually we do not accept anymore any eccentric residual regurgitation after a repair. Only trivial central regurgitation may be accepted in case of a very good coaptation of at least 5 to 8 mm with this coaptation being completely above the plane of the aortoventricular junction.
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