title: Assessment and repair of aortic valve cusp prolapse: implications for valve-sparing procedures.
abstract: OBJECTIVE
  Cusp prolapse causing aortic insufficiency is associated with unique echocardiographic, clinical, and surgical features. Recognition and appropriate surgical repair of this pathologic condition can not only treat affected patients but also improve results of aortic valve-sparing procedures, for which pre-existing or induced cusp prolapse is an important cause of failure.
  
  
  METHODS
  Of 428 patients undergoing aortic valve repair, 195 (46%) were treated for cusp prolapse, and 111 (57%) of those had trileaflet aortic valve and make up this cohort. Cusp disease was the sole mechanism for aortic insufficiency (isolated group) in 50 patients whereas aortic dilatation was contributory in 61 (associated group). In total, 144 cusps were repaired in 111 patients. Preoperative echocardiograms, intraoperative findings, and clinical and echocardiographic outcomes were reviewed.
  
  
  RESULTS
  On preoperative echocardiography, presence of an eccentric aortic insufficiency jet, regardless of severity, had 92% sensitivity and 96% specificity for the detection of single cusp prolapse. A transverse fibrous band was characteristically identified on the prolapsing cusp (sensitivity 57%; specificity 92%), correctly localizing a prolapsing cusp in all cases. Freedom from aortic valve reoperation at 8 years was 100% in the isolated group and 93% ± 5% in the associated group (p = 0.33). Freedom from recurrent aortic insufficiency (>2+) at 5 years was 90% ± 5% in the isolated and 85% ± 8% in the associated group (P = .54). The choice of surgical technique did not affect aortic insufficiency recurrence at follow-up (P = .6).
  
  
  CONCLUSIONS
  Recognition and repair of isolated aortic cusp prolapse provides durable midterm outcome. An eccentric aortic insufficiency jet and a fibrous band can aid in the diagnosis and localization of cusp prolapse associated with ascending aortic disease and may help to improve results of aortic valve-sparing procedures.
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Brussels, 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: Christine
authors.initials: C
authors.lastname: Watremez
authors.forename: David
authors.initials: D
authors.lastname: Glineur
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Vanoverschelde
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; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001023:Aortic Valve Prolapse / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D018618:Echocardiography, Doppler, Color; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome