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CLINICAL RESEARCH: CARDIAC SURGERY

Toward Predictable Repair of Regurgitant Aortic Valves

A Systematic Morphology-Directed Approach to Bicommissural Repair

Gösta B. Pettersson, MD, PhD^_*,_*, Adrian C. Crucean, MD^_*, Robert Savage, MD, FACC, Carmel M. Halley, MD, Richard A. Grimm, DO, FACC, Lars G. Svensson, MD, PhD, FACC^_*, Sepehre Naficy, MD^_*, A. Marc Gillinov, MD, FACC^_*, Jingyuan Feng, MS and Eugene H. Blackstone, MD, FACC^_*,

^_* Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
Department of Cardiovascular Anesthesia, Cleveland Clinic, Cleveland, Ohio
Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.

Manuscript received October 29, 2007; revised manuscript received December 17, 2007, accepted January 26, 2008.

^_* Reprint requests and correspondence: Dr. Gösta B. Pettersson, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue/Desk F24, Cleveland, Ohio 44195. (Email: petterg{at}ccf.org).

Objectives: Our purpose was to investigate a new approach to bicommissural repair of regurgitant aortic valves.

Background: Repair of regurgitant aortic valves is not widely accepted, but interest is increasing, particularly for bicuspid valves. We hypothesize that a systematic, segmental approach to morphology and corresponding morphology-directed repair will improve decision making and success.

Methods: From December 2001 to July 2007, a systematic surgical approach to valve analysis and bicommissural repair was applied prospectively to 63 consecutive patients with pure aortic valve regurgitation, mean age 40 ± 12 years. Cusp, commissure, and root morphologies were analyzed sequentially by direct inspection. Each abnormality was corrected by corresponding morphology-directed repair procedures. Retrospectively, 2 echocardiographic indexes—of tissue pliability (change in systolic to diastolic area) and coaptation deficiency (conjoint and reference cusp heights vs. "annulus" diameter)—were developed to evaluate repairability.

Results: Forty-two (67%) valves were repaired and 21 (33%) replaced. Regurgitation was related primarily to cusp (prolapse, restriction) and commissure (splaying) morphology; root pathology was less important. Morphology-directed repair included cusp maneuvers in all, commissural maneuvers in 71%, and root procedures in 33%. Restriction and cusp tissue deficiency limited repairability. Echocardiography reflected this in greater tissue pliability of successfully repaired valves compared with replaced ones (conjoint cusp 61 ± 16% vs. 34 ± 17%; reference cusp 65 ± 16% vs. 42 ± 16%; p = 0.0001) and less coaptation deficiency (1.06 ± 0.24 for repaired and 1.27 ± 0.19 for replaced valves; p = 0.002).

Conclusions: Systematic segmental analysis of morphology and a logical morphology-directed surgical approach facilitate aortic valve repair. Initial application of this paradigm suggests sufficient mobile cusp tissue is a key determinant of repairability.

Key Words: aortic valve repair • echocardiography • aortic surgery

Abbreviations and Acronyms   AR = aortic regurgitation   CDI = coaptation deficiency index   TEE = transesophageal echocardiogram   TNI = tissue normality index   TTE = transthoracic echocardiogram

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