Toward Predictable Repair of Regurgitant Aortic ValvesA 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.
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Figure 1 Cusp Repair Maneuvers
(A) Completed bicuspidalization equalizes free-margin length of the 2 cusps by suture closure of cleft in partially fused conjoint cusp with sufficient tissue. (B) Triangular resection (left 3 panels) or true plication (right panel) for prolapsing cusp with redundant tissue. (C) Shortening of free margin beyond equal length of the 2 cusps (overcorrection) improves competence in case of restriction. (D) Suture or patch closure with autologous pericardium of perforations, fenestrations, and tears. Occasionally, the free margin is reinforced using a running 7-0 polypropylene suture. Regurgitant orifice is delineated by free margin thickening, and cautious shaving is often done.
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Figure 2 Commissural Repair Maneuvers
(A) Commissural plication with a pledgeted suture (Cabrol stitch) corrects severe commissural separation and splaying, with edges of cusps approximated with figure-of-8 suture. (B) Cabrol-like stitch and figure-of-8 suture aligns commissure. (C) Reattachment or resuspension of detached commissure with a pledgeted suture on each side of commissure and plication of aortic wall with running horizontal suture above commissure. (D) Cabrol and Cabrol-like sutures at different commissural heights (high Cabrol stitches represent "classic" Cabrol stitches). Cabrol-like stitches placed lower reduce sinuses and "annulus," distort base of cusp, and narrow subcommissural triangle.
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Figure 4 TNI Illustrated and Calculated
(A) Bicuspid aortic valve repair. (B) Bicuspid aortic valve replacement. CC = conjoint cusp; RefC = reference cusp; TNI = tissue normality index.
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Figure 5 CDI Illustrated in 1 Repair and 1 Replacement Case
Asc Ao = ascending aorta; CDI = coaptation deficiency index; DAnnulus = annulus diameter; LVOT = left ventricular outflow tract; other abbreviations as in Figure 4.
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Figure 6 Comparison of Cusp Tissue Deficiency and Reduced Mobility Between Repaired and Replaced Valves
Box contains 50% of data points (25th and 75th percentiles), horizontal bar is the median value, and + sign the mean. (A) Coaptation deficiency index (CDI). (B) Tissue normality index (TNI) of reference cusps (gray boxes) and conjoint cusps (open boxes).
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Figure 7 Echocardiogram of Overcorrection
(Left) Diastolic color Doppler before (PRE) and after (POST) repair. (Right) During systolic ejection, illustrating trade-off of eliminating regurgitation for restricted opening and doming. LAX = long-axis view; SAX = short-axis view.
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