Aortic Valve Sparing Operations

Quantitative three-dimensional echocardiographic analysis of the bicuspid aortic valve and aortic root: A single modality approach

BACKGROUND

Patients with bicuspid aortic valves (BAV) are heterogeneous with regard to patterns of root remodeling and valvular dysfunction. Two-dimensional echocardiography is the standard surveillance modality for patients with aortic valve dysfunction. However, ancillary computed tomography or magnetic resonance imaging is often necessary to characterize associated patterns of aortic root pathology. Conversely, the pairing of three-dimensional (3D) echocardiography with novel quantitative modeling techniques allows for a single modality description of the entire root complex. We sought to determine 3D aortic valve and root geometry with this quantitative approach.

METHODS

Transesophageal real-time 3D echocardiography was performed in five patients with tricuspid aortic valves (TAV) and in five patients with BAV. No patient had evidence of valvular dysfunction or aortic root pathology. A customized image analysis protocol was used to assess 3D aortic annular, valvular, and root geometry.

RESULTS

Annular, sinus and sinotubular junction diameters and areas were similar in both groups. Coaptation length and area were higher in the TAV group (7.25 ±  0.98 mm and 298 ± 118 mm² , respectively) compared to the BAV group (5.67 ± 1.33 mm and 177 ± 43 mm² ; P = .07 and P = .01). Cusp surface area to annular area, coaptation height, and the sub- and supravalvular tenting indices did not differ significantly between groups.

CONCLUSIONS

Single modality 3D echocardiography-based modeling allows for a quantitative description of the aortic valve and root geometry. This technique together with novel indices will improve our understanding of normal and pathologic geometry in the BAV population and may help to identify geometric predictors of adverse remodeling and guide tailored surgical therapy.

Residual and Progressive Aortic Regurgitation After Valve-Sparing Root Replacement: A Propensity-Matched Multi-Institutional Analysis in 764 Patients

BACKGROUND

Residual/progressive aortic regurgitation (rAR, pAR) after valve-sparing aortic root replacement (V-SARR) can lead to reoperations. We sought to characterize risk factors of mild rAR and pAR after V-SARR in a multicenter cohort. The effect of additional cusp repair on valve function was analyzed using propensity matching.

METHODS

A total of 1,015 patients after V-SARR were identified with (n = 288, 28%) or without additional cusp/commissure repair (n = 727, 72%) at four cardiac units in Germany. A total of 764 patients fulfilling transthoracic echocardiography follow-up-criteria comprised the study cohort. Logistic regression was used for risk factor analysis with endpoints rAR, new onset AR, and pAR. t tests and analyses of variance were used for between-group differences. The effects of additional cusp repair on valve function were studied comparing propensity-matched quintiles.

RESULTS

The incidence of rAR was 29%, with influencing factors aneurysm size (p = 0.07) and preoperative aortic valve function (p = 0.08). It was found more often among nonsyndromic patients (34% vs. 14%; OR, 0.4; p < 0.001). Progression of rAR was detectable in 30% after a mean of 4.3 years. The progression rate of rAR ∼ 0.3 grades per patient-year within the first 5 years. When quintiles identified by propensity score were compared, additional cusp repair was linked to new onset AR (p = 0.016) while it was not linked to rAR (p = 0.14) or pAR (p = 0.5).

CONCLUSIONS

The incidences of rAR and pAR are considerable after V-SARR. Patients should be operated on before large aneurysms are present. New onset AR after an initially good functional result is more likely after an additional cusp repair, while rAR and pAR are not influenced by cusp repair.

A Simple Device for Morphofunctional Evaluation During Aortic Valve-Sparing Surgery

Valve-sparing operations for the treatment of aortic root disease with a structurally normal aortic valve are increasingly performed as they avoid prosthesis-related complications. Short- and long-term results are critically dependent on perfect intraoperative restoration of valve anatomy and function. Residual aortic regurgitation is the main cause of early failure, and it is the most common motive for reoperation. However, intraoperative morphofunctional valve assessment requires expertise, and only transesophageal echocardiography can provide reliable information. We describe a simple, economic, reproducible hydrostatic test to intraoperatively evaluate valve competency under direct visualization.

Valve-sparing aortic root replacement with translocation of anomalous left coronary artery

An anomalous left main coronary artery arising from the right coronary with a single coronary ostium is an exceptionally rare anatomic variant. Here, we report a patient with a left main coronary artery arising from the right coronary and also an aortic root aneurysm associated with mild aortic insufficiency. Valve-sparing aortic root replacement and coronary translocation were performed with an excellent outcome in this case.