Relevance of Leaflet Prolapse to the Indication Policy for Aortic Valve-Sparing Root Replacement

  • Andreas Borowski Department of Cardiovascular Surgery, University Hospital, Dusseldorf, Germany
  • Jan-Philipp Minol Department of Cardiovascular Surgery, University Hospital, Dusseldorf, Germany
  • Patric Kröpil Department of Radiology, University Hospital, Dusseldorf, Germany
  • Philipp Rellecke Department of Cardiovascular Surgery, University Hospital, Dusseldorf, Germany
  • Arash Mehdiani Department of Cardiovascular Surgery, University Hospital, Dusseldorf, Germany
  • Hannan Dalyanoglu Department of Cardiovascular Surgery, University Hospital, Dusseldorf, Germany


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.