Relevance of Leaflet Prolapse to the Indication Policy for Aortic Valve-Sparing Root Replacement
Background: In aortic root replacement, “preexisting” or “induced” aortic leaflet prolapse is related to advanced aortic root pathology and can indicate valve repair. Efforts should be made to perform root replacement before leaflet prolapse is in its maximum extent.
Materials and Methods: Thirty-nine patients with chronic aortic root dilatation and aortic valve regurgitation (AR) underwent a reimplantation procedure. Contrary to 32 of the 39 patients (group A), 7 of the 39 patients (group B) underwent cusp plication for prolapse. For both groups, data related to the diameter at the level of maximal tubular extension, sinotubular junction, sinus of Valsalva, aorto-ventricular junction (AVJ), and aortic annulus were obtained from preoperative computed tomography scans and analyzed comparatively.
Results: Group B showed a higher mean AR grade
(P = .007), a higher mean diameter at the level of the aortic annulus (P = .038), AVJ (P = .037), and aortic sinus (P <.001) and a higher sinus dilatation index (existing-to-predicted diameter ratio) (P <.001) than group A. The sinus of Valsalva displayed the best predictive value regarding a plicature-indicating prolapse (P <.001; 95% confidence interval [CI]: 0.809-1.013). A diameter >40 mm was accompanied by an odds ratio (OR) of 24.6 (95% CI: 1.29-496.02).
During the follow-up period of 29.0 ± 18.4 months (range: 6-62 months), 1 patient (group A) required reoperation 5 years postoperatively for progressive AR.
Conclusion: The sinus of Valsalva diameter seems to have the greatest prognostic value for the development of prolapse. Our data suggest that root repair should be considered earlier in time before leaflet prolapse is complete, which most likely occurs when root dilatation becomes an aneurysm.
Boodhwani M, de Kerchove L, Glineur D, et al. 2009. Repair-oriented classification of aortic insufficiency: impact on surgical techniques and clinical outcomes. J Thorac Cardiovasc Surg 2009;137:286-94.
Chester AH, Misfeld M, Yacoub MH. 2000. Receptor-mediated contraction of aortic valve leaflets. J Heart Valve Dis 9:250-4; discussion 254-5.
Cozijnsen L, Braam RL, Waalewijn RA, et al. 2011. What is new in dilatation of the ascending aorta? Review of current literature and practical advice for the cardiologist. Circulation 123:924-8.
David TE. 2014. Current readings: aortic valve-sparing operations. Semin Thorac Cardiovasc Surg 26:231-8.
David TE, Feindel CM. 1992. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 103:617-22; discussion 622.
Dawber TR, Meadors GF, Moore FE Jr. 1951. Epidemiological approaches to heart disease: the Framingham Study. Am J Public Health Nations Health 41:279-81.
Della Corte A, Romano G, Tizzano F, et al. 2006. Echocardiographic anatomy of ascending aorta dilatation: correlations with aortic valve morphology and function. Int J Cardiol 113:320-6.
Du Bois D, Du Bois EF. 1916. Clinical calorimetry: tenth paper[,] a formula to estimate the approximate surface area if height and weight be known. Arch Intern Med (Chic) 17:863-71.
El Khoury G, Vanoverschelde JL, Glineur D, et al. 2004. Repair of aortic valve prolapse: experience with 44 patients. Eur J Cardiothorac Surg. 26:628-33.
Erbel R, Aboyans V, Boileau C, et al. 2014. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC). Eur Heart J 35:2873-926.
Esaki J, Leshnower BG, Binongo JN, et al. 2017. Risk factors for late aortic valve dysfunction after the David V valve-sparing root replacement. Ann Thorac Surg 104:1479-87.
Green DM, Swets JA. 1966. Signal detection Theory and Psychophysics. New York: Wiley.
Hanley JA, McNeil BJ. 1982. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 143:29-36.
Kim DH, Handschumacher MD, Levine RA, et al. 2014. Aortic valve adaptation to aortic root dilatation: insights into the mechanism of functional aortic regurgitation from 3-dimensional cardiac computed tomography. Circ Cardiovasc Imaging 7:828-35.
Kunihara T, Aicher D, Rodionycheva S, et al. 2012. Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valve-preserving aortic root repair. J Thorac Cardiovasc Surg 143:1389-95.
Malvindi PG, Cappai A, Basciu A, et al. 2015. David operation: single center 10-year experience. J Cardiovasc Surg (Torino) 56:639-45.
Metz CE. 1978. Basic principles of ROC analysis. Semin Nucl Med 8:283-98.
Miyahara S, Omura A, Sakamoto T, et al. 2013. Impact of postoperative cusp configuration on midterm durability after aortic root reimplantation. J Heart Valve Dis 22:509-16.
Oka T, Okita Y, Matsumori M, et al. 2011. Aortic regurgitation after valve-sparing aortic root replacement: modes of failure. Ann Thorac Surg 92:1639-44.
Padial LR, Oliver A, Sagie A, Weyman AE, King ME, Levine RA. 1997. Two-dimensional echocardiographic assessment of the progression of aortic root size in 127 patients with chronic aortic regurgitation: role of the supraaortic ridge and relation to the progression of the lesion. Am Heart J 134(5 Pt 1):814-21.
Roman MJ, Devereux RB, Kramer-Fox R, O’Loughlin J. 1989. Two-dimensional echocardiographic aortic root dimensions in normal children and adults. Am J Cardiol 64:507-12.
Saliba E, Sia Y. 2015. The ascending aortic aneurysm: when to intervene? Dore A, El Hamamsy I, collaborators. Int J Cardiol Heart Vasc 6:91-100.
Schäfers HJ. 2015. Aortic valve repair: easy and reproducible? J Thorac Cardiovasc Surg 149:129-30.
Schäfers HJ, Aicher D. 2013. Root remodeling for aortic root dilatation. Ann Cardiothorac Surg 2:113-6.
Schäfers HJ, Raddatz A, Schmied W, et al. 2015. Reexamining remodeling. J Thorac Cardiovasc Surg 149(2 suppl):S30-6.
Settepani F, Cappai A, Basciu A, et al. 2016. Impact of cusp repair on reoperation risk after the David procedure. Ann Thorac Surg 102:1503-11.
Stephens EH, Liang DH, Kvitting JP, et al. 2014. Incidence and progression of mild aortic regurgitation after Tirone David reimplantation valve-sparing aortic root replacement. J Thorac Cardiovasc Surg 147:169-77, 178.e1-178.e3.
Swets JA. 1979. ROC analysis applied to the evaluation of medical imaging techniques. Invest Radiol 14:109-21.
Tanaka H, Takahashi H, Inoue T, et al. 2017. Which technique of cusp repair is durable in reimplantation procedure? Eur J Cardiothorac Surg 52:112-7.
Thubrikar MJ, Labrosse MR, Zehr KJ, Robicsek F, Gong GG, Fowler BL. 2005. Aortic root dilatation may alter the dimensions of the valve leaflets. Eur J Cardiothorac Surg 28:850-5.
Vasan RS, Larson MG, Levy D. 1995. Determinants of echocardiographic aortic root size. The Framingham Heart Study. Circulation 91:734-40.
Yacoub MH, Kilner PJ, Birks EJ, Misfeld M. 1999. The aortic outflow and root: a tale of dynamism and crosstalk. Ann Thorac Surg 68(3 suppl):S37-43.
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).