title: Toward predictable repair of regurgitant aortic valves: a systematic morphology-directed approach to bicommissural repair.
abstract: OBJECTIVE
  Our purpose was to investigate a new approach to bicommissural repair of regurgitant aortic valves.
  
  
  BACKGROUND
  Repair of regurgitant aortic valves is not widely accepted, but interest is increasing, particularly for bicuspid valves. We hypothesize that a systematic, segmental approach to morphology and corresponding morphology-directed repair will improve decision making and success.
  
  
  METHODS
  From December 2001 to July 2007, a systematic surgical approach to valve analysis and bicommissural repair was applied prospectively to 63 consecutive patients with pure aortic valve regurgitation, mean age 40 +/- 12 years. Cusp, commissure, and root morphologies were analyzed sequentially by direct inspection. Each abnormality was corrected by corresponding morphology-directed repair procedures. Retrospectively, 2 echocardiographic indexes--of tissue pliability (change in systolic to diastolic area) and coaptation deficiency (conjoint and reference cusp heights vs. "annulus" diameter)--were developed to evaluate repairability.
  
  
  RESULTS
  Forty-two (67%) valves were repaired and 21 (33%) replaced. Regurgitation was related primarily to cusp (prolapse, restriction) and commissure (splaying) morphology; root pathology was less important. Morphology-directed repair included cusp maneuvers in all, commissural maneuvers in 71%, and root procedures in 33%. Restriction and cusp tissue deficiency limited repairability. Echocardiography reflected this in greater tissue pliability of successfully repaired valves compared with replaced ones (conjoint cusp 61 +/- 16% vs. 34 +/- 17%; reference cusp 65 +/- 16% vs. 42 +/- 16%; p = 0.0001) and less coaptation deficiency (1.06 +/- 0.24 for repaired and 1.27 +/- 0.19 for replaced valves; p = 0.002).
  
  
  CONCLUSIONS
  Systematic segmental analysis of morphology and a logical morphology-directed surgical approach facilitate aortic valve repair. Initial application of this paradigm suggests sufficient mobile cusp tissue is a key determinant of repairability.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA. petterg@ccf.org
authors.forename: Gösta B
authors.initials: GB
authors.lastname: Pettersson
authors.forename: Adrian C
authors.initials: AC
authors.lastname: Crucean
authors.forename: Robert
authors.initials: R
authors.lastname: Savage
authors.forename: Carmel M
authors.initials: CM
authors.lastname: Halley
authors.forename: Richard A
authors.initials: RA
authors.lastname: Grimm
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.forename: Sepehre
authors.initials: S
authors.lastname: Naficy
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
authors.forename: Jingyuan
authors.initials: J
authors.lastname: Feng
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
mesh_terms: D000328:Adult; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery*; D004452:Echocardiography; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D011446:Prospective Studies; D012107:Research Design; D012189:Retrospective Studies; D014656:Vascular Surgical Procedures / Q000379:methods*