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J Thorac Cardiovasc Surg 2006;132:436-438
© 2006 The American Association for Thoracic Surgery

Brief Communication

A new approach to the assessment of aortic cusp geometry

Department of Thoracic and Cardiovascular Surgery, University Hospitals of Saarland, Homburg/Saar, Germany

Received for publication March 29, 2006; accepted for publication April 5, 2006.

^_* Address for reprints: Hans-Joachim Schäfers, MD, PhD, Department of Thoracic and Cardiovascular Surgery, University Hospitals of Saarland, 66421 Homburg/Saar, Germany (Email: h-j.schaefers{at}uniklinikum-saarland.de).

Repair of the aortic valve is a new surgical approach to the treatment of aortic regurgitation. Regurgitation of the aortic valve can be caused by cusp distortion, root dilatation, or a combination of both. For good functional reconstruction, all pathologic components present have to be addressed. Good results have been achieved with valve-preserving aortic replacement, ¹ but isolated aortic valve reconstruction (ie, cusp repair for prolapse) still remains a challenge to surgical judgment.

The main problem in repair of aortic cusps is assessment of pathology and the repair result. Root dilatation can easily be quantified preoperatively by means of echocardiography or intraoperative measurements. Cusp geometry, however, is difficult to quantify by means of echocardiography. Measurements of cusp dimensions are difficult to standardize intraoperatively, and these dimensions determine cusp configuration only in conjunction with sinus dimensions. ²

The typical configuration of a normal aortic valve is not only characterized by root dimensions but also the configuration of the cusps. This includes a typical height difference between the central free margins and the aortic insertion lines (Figure 1, A). ³ We have designed a caliper that allows easy and reproducible measurement of this height difference, which we call effective height as opposed to 2-dimensional cusp height. ² This measurement allows for identification of prolapse in the native cusps and assessment of prolapse correction after valve repair.

View larger version (50K): [in this window] [in a new window]   Figure 1. A, Schematic drawing of the aortic valve and root. Effective height is the height difference between the central free margins and the aortic insertion lines. This can be measured intraoperatively with a caliper. STJ, Sinutubular junction; AN, annulus or aortoventricular junction; LH, leaflet or cusp height; eH, effective height. B, Intraoperative photograph showing measurement of the effective height of the noncoronary cusp of a bicuspid aortic valve with the caliper. The caliper is placed such that the longer end rests on the lowest (ie, central) point of the insertion line. The shorter end is pushed to the free margin, with the curve accommodating the margin.

After cardioplegia, stay sutures are placed in the aortic commissures and kept under tension in the exact direction of the commissures (as seen from the center of the root). The caliper is placed such that the longer end rests on the lowest (ie, central) point of the insertion line. The shorter end is pushed to the free margin, with the curve accommodating the margin (Figure 1, B). The height difference of the cusp (free edge to insertion) can be measured in millimeters.

In normal aortic valves we have found effective height to range from 8 to 10 millimeters, which correlated ±1 mm with intraoperative transesophageal measurements. In approximately 50 repair operations, we have found good correlation between effective height measured intraoperatively and by means of postoperative echocardiography. Cusp prolapse found on preoperative echocardiography (Figure 2, A) was confirmed by means of intraoperative measurement. Cusp and valve configuration were normalized by shortening of the free margins to a height difference of 8 mm, with corresponding echocardiographic measurements (Figure 2, B).

View larger version (28K): [in this window] [in a new window]   Figure 2. A, Preoperative transesophageal echocardiogram of a patient who presented with grade III aortic regurgitation after valve reimplantation in a different institution. There is some prolapse of the fused cusp and an effective height of 4 mm. Both findings were confirmed by intraoperative measurements. B, Postoperative transesophageal echocardiogram of the same patient after shortening of both cusps. The valve is competent, and an effective height of 10 mm has been achieved.

Aortic cusp geometry has been defined by sinus dimensions, length of cusp insertion, cusp height, and length of free margin (ie, denominators that determine the 3-dimensional configuration as a prerequisite for normal valve function). Sinus dimensions can be determined by means of echocardiography, but cusp dimensions cannot be determined preoperatively. Even intraoperative measurement of parameters like cusp height, length of insertion line, or free margin is difficult. Most importantly, these parameters are only interdependent determinants of valve configuration, and their single relevance is limited.

Cusp prolapse can be an isolated pathology of the aortic valve and is often confined to one cusp both in bicuspid and tricuspid aortic valve anatomy. Prolapse can also coexist with root dilatation, and it might be induced by reduction of root diameters, particularly at the sinutubular level. Prolapse of one cusp can be recognized by comparing the relative length of the free margins. Prolapse of 2 or 3 cusps is much more difficult to assess because the reference points (the other cusp margins) are also abnormal. This is important in generalized prolapse, which can occur in the native valve ⁴ or as a consequence of valve-preserving surgery. ⁵ After reconstructive surgery, these valves function with acceptable regurgitation initially, but failure within the first years after repair has not been infrequent.

We have made the observation that repaired valves with low effective height between the free margin and aortic insertion progressed in regurgitation and required reoperation. In patients with aortic regurgitation, effective height has been as low as 4 mm (Figure 2, A). We have used an effective height of 8 mm or more as a goal in the past 50 aortic valve repairs and have been able to achieve good configuration and no regurgitation greater than grade I.

In conclusion, we propose to take effective cusp height into consideration in aortic valve repair and valve-preserving surgery. It can be measured intraoperatively and is a useful guide to quantify cusp prolapse and assess the results of valve-preserving surgery.

References

1. David TE, Ivanov J, Armstrong S, Feindel CM, Webb GD. Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta. Ann Thorac Surg 2002;74(suppl):S1758-S1761discussion S1792-9.[Abstract/Free Full Text]
   
2. Kunzelman KS, Grande KJ, David TE, Cochran RP, Verrier ED. Aortic root and valve relationships. Impact on surgical repair. J Thorac Cardiovasc Surg 1994;107:162-170.[Abstract/Free Full Text]
   
3. Swansson WM, Clark RE. Dimensions and geometric relationships of human aortic valve as a function of pressure. Circ Res 1974;35:871-882.[Abstract/Free Full Text]
   
4. Shapiro M, Thwaites B, Westgate C, Donaldson R. Prevalence and clinical significance of aortic valve prolapse. Br Heart J 1985;54:179-183.[Abstract/Free Full Text]
   
5. Pethig K, Milz A, Hagl C, Harringer W, Haverich A. Aortic valve reimplantation in ascending aortic aneurysm. risk factors for early valve failure. Ann Thorac Surg 2002;73:29-33.[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Benjamin Bierbach Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schäfers, H.-J. Articles by Aicher, D. Search for Related Content PubMed PubMed Citation Articles by Schäfers, H.-J. Articles by Aicher, D. Related Collections Valve disease