title: Aortic valve repair with ascending aortic aneurysms: associated lesions and adjunctive techniques.
abstract: OBJECTIVE
  Patients with supracoronary ascending aortic aneurysms can have aortic insufficiency (AI) due to dilatation of the sinotubular junction and/or associated cusp pathology. The incidence and types of cusp lesions as well as the effect of AI severity and cusp repair techniques on outcome in this patient population is not well defined.
  
  
  METHODS
  Since 1996, 55 patients (mean age: 65 ± 13 years, 17 bicuspid valves) presented with supracoronary ascending aortic aneurysms and AI that was mild/moderate in 27 (49%) and severe in 28 (51%). Associated pathology included cusp prolapse in 18 (33%), cusp restriction in nine (16%) and both in three (5%). All patients underwent aortic replacement and remodeling of the sinotubular junction. Adjunctive techniques included subcommissural annuloplasty in 38(69%) and cusp repair in 28 (51%).
  
  
  RESULTS
  AI severity was not significantly associated with the presence of cusp pathology (p=0.35). Cusp disease was present in 100% of bicuspid aortic valves compared with only 34% of trileaflet valves (p<0.001). There was no hospital mortality and overall survival was 94 ± 4% and 75 ± 10%, respectively, at 5 and 7 years. Freedom from re-operation was 100% at 7 years and freedom from recurrent AI (>2+) was 87 ± 7% at 5 years. Neither the presence of preoperative severe AI, nor the need for cusp repair was predictive of late outcome.
  
  
  CONCLUSIONS
  Cusp pathology is frequently encountered in patients with ascending aortic dilatation and AI. Severe AI is not a contraindication to valve-preserving surgery, but careful identification and repair of cusp pathology, in addition to sinotubular junction reduction, is critical for durable, long-term outcome.
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Cardiology Cliniques Universitaires Saint-Luc, Brussels 1200, Belgium. mboodhwani@ottawaheart.ca
authors.forename: Munir
authors.initials: M
authors.lastname: Boodhwani
authors.forename: Laurent
authors.initials: L
authors.lastname: de Kerchove
authors.forename: David
authors.initials: D
authors.lastname: Glineur
authors.forename: Jean
authors.initials: J
authors.lastname: Rubay
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Vanoverschelde
authors.forename: Michel
authors.initials: M
authors.lastname: Van Dyck
authors.forename: Philippe
authors.initials: P
authors.lastname: Noirhomme
authors.forename: Gebrine
authors.initials: G
authors.lastname: El Khoury
mesh_terms: D000328:Adult; D000368:Aged; D001014:Aortic Aneurysm / Q000150:complications / Q000601:surgery*; D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000209:etiology / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D058385:Cardiac Valve Annuloplasty / Q000379:methods; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D016896:Treatment Outcome