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J Thorac Cardiovasc Surg 2009;137:286-294
© 2009 The American Association for Thoracic Surgery
Acquired Cardiovascular Disease |
Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
Received for publication May 5, 2008; revisions received July 30, 2008; accepted for publication August 31, 2008. * Address for reprints: Gébrine El Khoury, MD, Service de Chirurgie Cardiovasculaire et Thoracique, Cliniques Universitaires Saint-Luc UCL 90, Ave Hippocrate 10, Brussels B-1200, Belgium. (Email: elkhoury{at}chir.ucl.ac.be).
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Abstract |
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Methods: From 1996 to 2007, 264 patients underwent elective aortic valve repair for aortic insufficiency (mean age – 54 ± 16 years; 79% male). AV was tricuspid in 171 patients bicuspid in 90 and quadricuspid in 3. One hundred fifty three patients had type I dysfunction (aortic dilatation), 134 had type II (cusp prolapse), and 40 had type III (restrictive). Thirty six percent (96/264) of the patients had more than one identified mechanism.
Results: In-hospital mortality was 1.1% (3/264). Six patients experienced early repair failure; 3 underwent re-repair. Functional classification predicted the necessary repair techniques in 82-100% of patients, with adjunctive techniques being employed in up to 35% of patients. Mid-term follow up (median [interquartile range]: 47 [29–73] months) revealed a late mortality rate of 4.2% (11/261, 10 cardiac). Five year overall survival was 95 ± 3%. Ten patients underwent aortic valve reoperation (1 re-repair). Freedoms from recurrent Al (>2+) and from AV reoperation at 5 years was 88 ± 3% and 92 ± 4% respectively and patients with type I (82 ± 9%; 93 ± 5%) or II (95 ± 5%; 94 ± 6%) had better outcomes compared to type III (76 ± 17%; 84 ± 13%).
Conclusion: Aortic valve repair is an acceptable therapeutic option for patients with aortic insufficiency. This functional classification allows a systematic approach to the repair of Al and can help to predict the surgical techniques required as well as the durability of repair. Restrictive cusp motion (type III), due to fibrosis or calcification, is an important predictor for recurrent Al following AV repair.
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Introduction |
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In recent years, there has been increasing interest in valve-sparing surgery to treat pathology of the aortic valve and root. Valve-sparing aortic root replacement, pioneered by David and Feindel1
and Yacoub and coworkers,2 has standardized the treatment of aortic root pathology and helped to lay the foundation for the application of repair techniques to the aortic valve. Patients with dilatation of the aortic root and ascending aorta, however, commonly have concomitant cusp pathology that requires treatment.3,4 Furthermore, aortic insufficiency (AI) may occur in the absence of aortic pathology as a result of primary cusp disease.5 Repair techniques for the aortic valve, particularly for cusp pathology, remain heterogeneously and infrequently applied and have not been systemically characterized. A major limitation to the more generalized application of aortic valve repair techniques is the absence of a common framework for valve assessment to guide the approach to valve repair.
Important lessons in this regard may be learned from the development of mitral valve repair. The Carpentier classification6 of mitral valve insufficiency was responsible, in large part, for the development and generalized dissemination of repair techniques for the mitral valve, because it provided a common language for cardiologists, anesthesiologists, and surgeons to communicate about disease mechanisms and pathology. Key characteristics of that classification system were that it encompassed the entire spectrum of disease, it clarified and provided insight into the mechanism of insufficiency, it could be consistently applied with different assessment modalities (echocardiography and surgical assessment), it guided the repair techniques, and, finally, it provided a framework for the assessment of long-term outcome for differing mitral valve pathologic entities.
During the past decade, we have developed a similar classification of aortic valve insufficiency with these characteristics in mind.7 The purpose of this study was to describe our experience with aortic valve repair for AI according to this systematic approach and to evaluate this classification system specifically with respect to its ability to guide surgical repair and predict clinical outcome.
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Materials and Methods |
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Classification of AI
During a similar period, a classification system for AI according to mechanisms of disease and the repair techniques used was developed and applied to this patient population (Figure 1
).7 This classification centers around the idea that the aortic valve, much like the mitral valve, consists of two major components, the aortic annulus and the valve leaflets. Unlike that of the mitral valve, however, the annulus of the aortic valve is not a single anatomic structure. The functional aortic annulus rather consists of two separate components, the ventriculoaortic junction (VAJ) and the sinotubular junction (STJ). As in the Carpentier classification of mitral valve disease, regurgitation associated with normal leaflet motion is designated as type I. Type I AI is largely due to lesions of the functional aortic annulus, with type 1a AI resulting from STJ enlargement and dilatation of the ascending aorta, type Ib resulting from dilatation of the sinuses of Valsalva and the STJ, type Ic resulting from dilatation of the VAJ, and type 1d resulting from cusp perforation without a primary functional aortic annular lesion. Type II AI is due to leaflet prolapse as a result of excessive cusp tissue or commissural disruption. Type III AI is due to leaflet restriction, which may be found in bicuspid, degenerative, or rheumatic valvular disease as a result of calcification, thickening, and fibrosis of the aortic valve leaflets.
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Surgical Techniques
Intraoperative transesophageal echocardiography was routinely performed. All procedures were performed through a median sternotomy. The ascending aorta or proximal aortic arch was cannulated, along with either single, two-stage right atrial cannulation or bicaval venous cannulation, depending on the concomitant procedures being performed. After systemic heparinization, the aorta was crossclamped, and antegrade warm, blood cardioplegia was administered either through the aortic root or through direct coronary ostial cannulation after aortotomy. A transverse aortotomy was performed approximately 1 cm above the STJ, and three 4-0 polypropylene sutures were placed at the level of the commissures for exposure. The aortic valve was assessed for the mechanisms of AI, and the echocardiographic findings were corroborated.
Similar to those for the mitral valve, aortic valve repair techniques follow the broad principle of correcting the lesion identified according to the classification. In cases of leaflet repair, a functional aortic annuloplasty is added to stabilize the repair. Annuloplasty to the functional aortic annulus has to be performed both proximally (VAJ) and distally (STJ) and may be performed with or without an aortic prosthesis. At the VAJ, annuloplasty may be accomplished by a valve-sparing root replacement procedure (eg, aortic valve reimplantation) or by performing subcommissural annuloplasty. Of note, an aortic valve remodeling procedure requires subcommissural annuloplasty for proximal annular stabilization. Subcommissural annuloplasty is performed to stabilize the VAJ and reduce the width of the interleaflet triangle, as previously described elsewhere,5 with 2-0 pledgeted valve sutures. Annuloplasty at the STJ may be performed with a Dacron polyester fabric aortic tube graft of the appropriate diameter or by placing plication sutures at the STJ. For type II lesions, leaflet prolapse can be corrected with a variety of previously described techniques, including triangular resection (with or without pericardial patch repair), leaflet plication, and free margin resuspension.5 For type III or restrictive leaflet disease, shaving and decalcification of leaflets is required, with or without patching. The specific techniques recommended to address the mechanism for each class of AI are indicated in Figure 1. For each lesion type, the primary repair technique addresses the mechanism of the regurgitant lesion and the secondary technique typically involves stabilization of annulus through annuloplasty of the functional aortic annulus. In some cases, adjunctive repair techniques are used for intraoperatively discovered pathologic entities, not adequately diagnosed on preoperative echocardiography or for induced leaflet pathologic problems, such as induced leaflet prolapse after a valve-sparing root replacement procedure.
After the completion of repair, transesophageal echocardiography is critical for valve assessment. It was therefore performed in all patients specifically to assess the degree of AI, the orientation of the regurgitant jet (if present), and the coaptation length and coaptation level of the aortic valve cusps. Coaptation length of at least 5 mm at the midportion of the free margin and a coaptation level above the aortic valve annulus was a prerequisite for a successful repair, and the presence of an eccentric residual AI jet was an indication for reexploration of the aortic valve.
Postoperative Care
All patients were treated with aspirin after the operation and underwent transthoracic echocardiography before discharge.
Follow-up
Clinical follow-up was conducted either through outpatient visits or as telephone follow-up conducted by a research nurse. In addition to survival status, information on valve-related complications including thromboembolism, hemorrhage, endocarditis, reoperation, and cardiovascular symptoms was obtained whenever possible. Transthoracic echocardiography was performed for all patients after discharge and at regular intervals during the course of follow-up. Echocardiograms not obtained at our institution were interpreted by the referring cardiologist.
Statistical Analysis
Data are presented as mean ± SEM for continuous data or as median with interquartile range for nonparametric data. Failure time data for survival, reoperation, and recurrent AI are presented with Kaplan–Meier survival curves. Comparisons between groups for failure time data were performed with the log-rank test. Statistical analyses were performed with SAS version 9.1 software (SAS Institute, Inc, Cary, NC). Graphs were constructed with GraphPad Prism 4.0 (GraphPad Software, Inc, San Diego, Calif).
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Results |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionsReferences |
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2+) underwent aortic valve repair with or without aortic root, ascending aortic and concomitant cardiac procedures. Table 1
depicts the preoperative characteristics of study patients. The mean age was 54 ± 16 years, with about 80% of patients being male. More than 70% of patients had symptoms (New York Heart Association functional class II), and most had normal left ventricular ejection fractions. The most common etiology of AI was degenerative, followed by bicuspid aortic valve, Marfan syndrome, and endocarditis. For 43% of patients, the AI was the primary indication for surgery. For the remaining 53% of patients, who had both aortic dilatation and AI, the mean maximal aortic diameter was 53 ± 9 mm.
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Discussion |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionsReferences |
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Classification of disease mechanisms can aid in the treatment of disease. In the case of AI, our classification system has successfully provided a common language for use among cardiologists, anesthesiologists, and surgeons in the description of AI and its mechanisms. We have previously demonstrated that there is excellent correlation between echocardiographic and surgical assessments of the aortic valve with respect to disease classification.8 Furthermore, this classification can be used to guide the repair techniques, thus standardizing the approach to the surgical repair of AI. In our cohort, we found that the vast majority of patients with either single or multiple lesions underwent repair with the techniques predicted by our disease classification. Adjunctive techniques not predicted by the classification, however, were used for as many as 35% of patients on the basis of intraoperative findings. The most common adjunctive techniques were the addition of leaflet repair in type Ic disease and the addition of STJ plication in type II and type III disease. The addition of leaflet repair in primary functional aortic annular disease (eg, type Ic) likely reflects the intraoperative discovery of previously missed leaflet pathology or induced leaflet prolapse after reduction of functional aortic annulus. STJ plication, added in about 30% of type II and III disease cases, is consistent with the notion of the two separate components of the functional aortic annulus, the VAJ and the STJ, that need to be stabilized during aortic valve repair. Overall, these findings reinforce the idea that although the key aspects of aortic valve repair can be systematically predicted by using this classification system, important roles still remain for intraoperative valve assessment and subjective decision making by the operating surgeon.
An important feature of a disease classification is the prognostic information it provides to optimize patient selection and guide treatment. In our experience, type III AI, caused by cusp restriction, was predictive of midterm AI recurrence. Although reoperation rates were not significantly different, this information is an important factor to incorporate into the decision making regarding repair versus replacement of the aortic valve. Interestingly, cusp anatomy (ie, number of cusps) had no impact on midterm clinical or echocardiographic outcome. Classification of AI also provides the ability to compare midterm and long-term clinical outcomes of different repair techniques in a comparable group of patients.
Other classification systems have been proposed for aortic valve disease. Haydar and colleagues9 presented a classification system that they applied to 44 patients with AI. Their cohort consisted primarily of young patients (mean age 33 years), with most having congenital aortic valve disease (68%). Although they classified AI into three types (caused by annular dilatation, redundant leaflet tissue, and deficient leaflet tissue), they did not specifically classify patients with aortic root and ascending aortic pathology, which is a common cause of AI in adults, or those with cusp perforation or rupture of fenestrations. Lansac and associates10 recently reported a detailed classification system for AI that was based on postmortem assessment. Their proposed system provides limited information regarding reparability, however, because valve-sparing surgery was performed in fewer than 10% of their cases, and the degree of AI in that population was not reported. Furthermore, no specific correlations between echocardiographic and pathologic findings were reported. Finally, Sievers and colleagues11 have described a detailed anatomic classification of bicuspid aortic valves according to pathologic examination; this provides useful anatomic information but is not specifically geared toward repair techniques. In contrast, our classification both successfully encompasses all anatomic subsets of AI and provides insight into mechanisms and surgical treatment.
Aortic valve repair has numerous potential advantages relative to prosthetic valve replacement. First, it preserves the dynamic native aortic valve annulus and native valve tissue, which may have hemodynamic benefits relative to a rigid prosthetic valve stent. Second, avoidance of a mechanical prosthesis, which would often be used in this young population, reduces the risk of thromboembolic and anticoagulation-related complications. Finally, valve repair has been proposed to carry a low incidence of valve endocarditis.12 In 1171 years of patient follow-up, we saw only 1 case of endocarditis, which corresponds to a linearized rate of 0.08% per patient-year. Furthermore, only 5 patients in our cohort had events that could be attributed to thromboembolism, yielding a linearized rate of 0.43% per patient-year, which is approximately half the rate reported for prosthetic aortic valves.13,14 The risk of reoperation for disease recurrence is perhaps the most important factor when comparing repair with bioprosthetic valve replacement. In our experience, the risk of aortic valve reoperation was acceptable for this young cohort of patients, with a freedom from reoperation of 91% at 8 years overall. For patients with type I or II disease, the freedom from reoperation was 94% at 8 years. Similar results have been reported by others in contemporary literature .12,15 It is important to note in this context that rates of modern bioprosthetic structural valve deterioration are significantly higher among younger patients (3.7%/year in patients younger than 50 years and about 2%/year in patients between 50 and 60 years old).16 It is likely that increasing experience with valve repair techniques, as well as optimal patient selection, will help to improve the durability of aortic valve repair. Finally, an aortic valve reoperation after repair is theoretically simpler from a technical perspective than one after placement of a stented or stentless prosthesis. Ultimately, the decision to propose aortic valve repair versus replacement needs to incorporate numerous patient- and disease-specific factors, patient preferences, and the surgeon's experience. Longer-term follow-up data will help to guide this decision making, particularly for younger patients with aortic valve disease.
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Conclusions |
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Footnotes |
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References |
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