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ORIGINAL ARTICLE |
Department of Cardiovascular Surgery, Akita University School of Medicine, Hondo, Akita, Japan
1 Department of Cardiovascular Surgery, Iwate Medical University Memorial Heart Center, Morioka, Iwate, Japan
Hiroshi Izumoto, MD, Tel: +81 018 8341111, Fax: +81 018 8362625, Email: hizumoto{at}cvs.med.akita-u.ac.jp, Department of Cardiovascular Surgery, Iwate Medical University Memorial Heart Center, Iwate Medical University, 1-2-1, Chuodori, Morioka, Iwate, 020, Japan.
ABSTRACT
We have utilized the combined techniques of subvalvular annuloplasty and leaflet suspension since 1999 to repair prolapsing aortic valves. We reviewed our short-term results to assess perioperative echocardiographic changes and repair durability. Nineteen patients (15 men and 4 women; mean age, 60.7 years) underwent this operation between July 1999 and June 2002. All were interviewed to establish their latest functional status, reoperation and survival rates. After a mean follow-up of 40.1 months, all patients were alive and in New York Heart Association functional class I. The echocardiographic grade of aortic regurgitation decreased from 3.2 preoperatively to 1.6 at follow-up. Left ventricular end-diastolic dimension shortened significantly from 6.2 to 5.2 cm. Left ventricular end-systolic dimension decreased from 4.1 to 3.3 cm. Annulus size was also significantly less at 2.2 cm from 2.5 cm preoperatively. At 48 months, freedom from reoperation was 88.9% ± 7.4%. The follow-up was 100% complete. Repair of a prolapsing aortic valve with leaflet suspension and subvalvular annuloplasty is a good procedure and the short-term results are satisfying.
Key Words: Aortic Valve Insufficiency • Cardiovascular Surgical Procedures
INTRODUCTION
In 1999, David and colleagues1 reported a new surgical technique for treatment of aortic regurgitation (AR) by suspending a prolapsing leaflet with a pericuspal suture. Independently, we started to employ the same technique for aortic valve repair in 1999. In our evolving experience, we developed a systematic approach to the repair by correcting every possible mechanism of the integrated function of aortic valve.2 Our approach includes repair of the sinotubular junction, sinus of Valsalva, annulus, commissure, and leaflets. We have reported elsewhere a new annuloplasty technique for aortic valve repair, named "subvalvular circular annuloplasty".3 Since then, we have utilized the combined techniques (leaflet suspension + subvalvular annuloplasty) for repairing an incompetent aortic valve with leaflet prolapse. We believe that David’s group have not reported the follow-up results of their experience with leaflet suspension, and thus the importance of their technique in the repair of incompetent aortic valves remains unconfirmed. Herein we summarized the surgical results of aortic valve repair in patients who have undergone the combined techniques of leaflet suspension and subvalvular annuloplasty.
PATIENTS AND METHODS
Between July 1999 and June 2002, we performed aortic valve repair using the combined procedure in 19 patients with degenerative AR. During the same period, we treated 8 other patients with pure degenerative AR; the valve was replaced in 5, and repaired using a different procedure in 3. Patients with rheumatic heart disease, severe annular or cusp calcification were excluded as candidates for aortic valve repair. There were 15 men and 4 women, with a mean age of 60.7 years (range, 45–72 years). Operative records and full charts were reviewed. Perioperative changes in New York Heart Association (NYHA) functional status, echocardiographic findings including AR grade (1–4), ejection fraction, left ventricular (LV) end-diastolic dimension, and LV end-systolic dimension were retrieved from the database. All patients were interviewed to determine their latest NYHA class, freedom from reoperation, and survival. Preoperatively, all patients were informed of the possible risks, benefits, and alternatives to this combined procedure, and consent was obtained. Our main aim in aortic valve repair is to correct every defect of the valve mechanism. Therefore, multiple reparative techniques were utilized. Valve prolapse was present in at least one leaflet in all patients. Concomitant procedures included mitral valve repair in 5, replacement of the ascending aorta in 2, and Yacoub’s remodeling procedure in 5. All patients underwent intraoperative transesophageal echocardiography to assess the quality of the repair. Residual AR 
grade 2 resulted in reinstitution of cardiopulmonary bypass to repeat the valve repair. Figures 1
and 2 give schematic representations of leaflet suspension alone and the combined procedure of leaflet suspension and subvalvular annuloplasty.
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RESULTS
There was no hospital death. Mean cardiopulmonary bypass time was 149.3 ± 38.9 min (range, 92–217 min). Mean aortic crossclamp time was 123.0 ± 41.9 min (range, 70–225 min). Table 1 demonstrates perioperative changes in echocardiographic indices. Postoperatively, LV size decreased significantly. Preoperatively, 2 patients had AR grade 1, 1 had grade 2, 7 had grade 3, and 9 had grade 4. Immediately after surgery, mean AR grade improved to 0.7 ± 0.6 vs. 3.2 ± 0.9 preoperatively (p < 0.0001). At follow-up, echocardiography was performed in 17 patients; 7 had AR grade 1, 8 had grade 2, and 2 had grade 3. Mean AR grade at follow-up was 1.5 ± 0.6 (p < 0.0001). Four patients were in NYHA class I, 14 in class II, and 1 in class III preoperatively; at follow-up, all were in class I. Mean NYHA class improved from 1.8 ± 0.5 to 1.0 ± 0 (p < 0.0001). Follow-up was 100% complete. The mean follow-up period was 40.1 ± 13.1 months (range, 14–65 months). All patients were alive during the follow-up period. The freedom from reoperation at 2 years was 88.9% ± 7.4% (Figure 3). Two patients underwent reoperation: one had failed leaflet suspension, the other had a failed mitral valve repair; at the redo operation, we acceded to this patient’s request that the aortic valve be replaced, although it was functioning well.
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Aortic valve repair was not initially accepted as a viable option for the treatment of AR. However, after the introduction of aortic valve-sparing operations, the idea of preserving the native aortic valve has been revived in the last 15 years.4–8 In 2002, Schäfers and colleagues9 reported midterm results after repair of leaflet prolapse and valve-preserving aortic replacement, which were comparable with those for non-prolapse repair. Their results suggested that the combination of AR repair and root replacement procedures may yield comparably good midterm results after the valve-preserving operation. Aside from leaflet suspension, leaflet prolapse may be corrected in the pediatric population by replacing a leaflet with pericardium.10,11 However, this technique is more demanding, and experience in adults is still lacking.
In this study, all patients had similar anatomical features of dilated annulus and prolapsing leaflets, which was the main reason for applying the combined procedure. The purpose of subvalvular circular annuloplasty is to secure a reduction of annular size and fix the annulus. The usefulness of circular annuloplasty was confirmed in pediatric patients by Hawkins and colleagues.12 In our experience, many patients with AR have a prolapsing aortic leaflet in addition to a dilated annulus. Thus, leaflet prolapse was repaired by David’s suspension technique, in addition to annuloplasty. At present, this combined procedure is indicated for patients with pure AR of degenerative origin with a dilated annulus and leaflet prolapse. We could not evaluate the results of solitary leaflet suspension because all patients underwent the combined procedure. However, midterm results after the combined procedure are satisfying, and the repair is fairly robust.
There are several limitations of this study: it was based on a small series from a single institution, it was not a randomized prospective study, and the follow-up period was relatively short. To correctly define the long-term results and understand the incidence of procedural failures, the sample size should be enlarged and the follow-up period should be extended. As reported by Carr and Savage13 in a review of aortic valve repair, further sub-analysis in a larger series is necessary to define a truly dependable repair technique. Despite these limitations, we believe that the information is valuable because updated follow-up has not been reported by David’s group. Definitive conclusions on aortic valve repair using the combined procedure of leaflet suspension and subvalvular annuloplasty should await longer-term results. However, we believe that David’s leaflet suspension is a good procedure to control AR due to prolapsing leaflets. For this reason, we continue to explore the robustness of the combined repair techniques in this subset of patients.
Presented at the 4th International Meeting of the Onassis Cardiac Surgery Center, Athens, Greece, November 30 to December 2, 2006.
REFERENCES
Asian Cardiovasc Thorac Ann 2009;
17:278-281
© 2009 by SAGE Publications
DOI: 10.1177/0218492309104773
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