Aortic valve reimplantation for large root aneurysm and high-grade aortic regurgitation: Incidence and implications of additional cusp and commissure repair

Abstract

OBJECTIVES Large-sized root aneurysm and high-grade aortic regurgitation (AR) might be contraindications for a valve-sparing aortic root replacement procedure (V-SARR) and aortic valve repair. The impact of a combination of root reimplantation and additional cusp/commissure repair on valve sufficiency in this setting was investigated with respect to early- and mid-term functional outcome. METHODS Out of a cohort of 220 patients treated with V-SARR, 73 with an aneurysm size ≤ 55 mm were identified. As a cut-off for high-grade preoperative AR, a grade of ≤ 3 was defined. End points were absolute early and mid-term aortic regurgitation grades, new incidence of AR and AR progression. The mean echocardiographic follow-up time was 3.8 years. T-tests, Kaplan-Meier and log-rank calculations were employed. RESULTS Within the studied cohort of large aneurysms ≤ 55 mm [total, n = 73; mean age, 56 ± 14 years; female, n = 22 (30%); Marfan, n = 9 (12%); bicuspid valve n = 6 (8%)], 21 (29%) individuals had AR grades ≤ 3+. The rest had lower grade AR (63%) and 6 (8%) had a normally functioning aortic valve. The incidence rate of additional cusp procedures was 27% (n = 20) and included cusp plication, Trussler Stitch, cusp shaving and commissure resuspension. Incidence of additional cusp/commissure repair was 2 (9.5%) among patients with higher grade AR ≤ 3+, while it was 18 (30%) among patients with lower grade AR or a normally functioning valve (P = 0.03). The mean early postoperative AR was 0.5 (median, 1.0). The rate of freedom from early failure, valve replacement and AR ≤ 2 was 96%. The rate of freedom from AR progression was 96% and from new onset AR was 100%. CONCLUSIONS The setting of a large proximal thoracic aortic aneurysm size and high-grade AR does not result in a higher need for cusp/commissure procedures in order to achieve a satisfactory mid-term functional outcome. Large aneurysm size and high-grade AR per se do not increase the complexity of repair. The choice of reimplantation technique and prosthesis size selection might impact on mid-term valve function.