title: Leaflet reconstructive techniques for aortic valve repair.
abstract: BACKGROUND
  Refining leaflet reconstruction has become a primary issue in aortic valve repair. This descriptive analysis reviews leaflet pathology, repair techniques, and early results in a prospective regulatory trial of aortic valve repair.
  
  
  METHODS
  Sixty-five patients underwent valve repair for predominant moderate to severe aortic insufficiency (AI). The mean age was 63 ± 13 years, and 69% of the patients were male. Ascending aortic/root replacement was required in 62%. As a first step, ring annuloplasty was performed, and then leaflet repair included leaflet plication for prolapse, nodular unfolding, double pericardial patching of commissural defects or holes, complete pericardial leaflet replacement, leaflet extension, and Gore-Tex reinforcement. Leaflet techniques and causes of adverse outcomes were evaluated.
  
  
  RESULTS
  The follow-up time was 2-years maximal and 0.9 years mean, with a survival of 97%. Eighty percent of patients required repair of leaflet defects: leaflet prolapse (52/65-80%), ruptured commissures (6/65-9%), leaflet holes (4/65-6%), and nodular retraction (6/65-9%). The average preoperative AI grade of 2.9 ± 0.8 fell to 0.7 ± 0.7 (p < 0.0001). Three patients (4.6%) required interval valve replacement because of (1) suture untying, (2) iatrogenic leaflet tear, or (3) diphtheroid endocarditis. Five other patients experienced grade 2 or grade 3 AI: probable suture untying in 1 patient, ineffective leaflet extensions in 2 patients, and unsuccessful Gore-Tex reinforcements in 2 patients. Two patients with single pericardial leaflet replacements and all those with double pericardial reconstructions did well.
  
  
  CONCLUSIONS
  Leaflet defects are common in patients with moderate to severe AI. Leaflet plication, nodular unfolding, and double pericardial patching performed well. Gore-Tex and leaflet extension seemed less satisfactory. Standardization and experience with leaflet reconstruction will be important for optimizing the outcomes of aortic valve repair.
authors.affiliation: German Heart Center Munich, Munich, Germany.
authors.forename: Domenico
authors.initials: D
authors.lastname: Mazzitelli
authors.affiliation: German Heart Center Berlin, Berlin, Germany.
authors.forename: Christof
authors.initials: C
authors.lastname: Stamm
authors.affiliation: Vanderbilt University, Nashville, Tennessee. Electronic address: jsrankinmd@cs.com.
authors.forename: J Scott
authors.initials: JS
authors.lastname: Rankin
authors.affiliation: Klinikum Nuernberg, Nuernberg, Germany.
authors.forename: Steffen
authors.initials: S
authors.lastname: Pfeiffer
authors.affiliation: Klinikum Nuernberg, Nuernberg, Germany.
authors.forename: Theodor
authors.initials: T
authors.lastname: Fischlein
authors.affiliation: Institute for Clinical and Experimental Medicine, Prague, Czechoslovakia.
authors.forename: Jan
authors.initials: J
authors.lastname: Pirk
authors.affiliation: University of Cologne, Cologne, Germany.
authors.forename: Yeong-Hoon
authors.initials: YH
authors.lastname: Choi
authors.affiliation: University Heart Center, Hamburg, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Detter
authors.affiliation: Albert-Ludwigs-University, Freiburg, Germany.
authors.forename: Johannes
authors.initials: J
authors.lastname: Kroll
authors.affiliation: Albert-Ludwigs-University, Freiburg, Germany.
authors.forename: Friedhelm
authors.initials: F
authors.lastname: Beyersdorf
authors.affiliation: Hannover Medical School, Hannover, Germany.
authors.forename: Malakh
authors.initials: M
authors.lastname: Shrestha
authors.affiliation: German Heart Center Munich, Munich, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Schreiber
authors.affiliation: German Heart Center Munich, Munich, Germany.
authors.forename: Rüdiger
authors.initials: R
authors.lastname: Lange
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000601:surgery*; D058385:Cardiac Valve Annuloplasty / Q000379:methods*; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010496:Pericardium / Q000637:transplantation*; D012189:Retrospective Studies; D013524:Surgical Flaps; D013536:Suture Techniques; D013997:Time Factors; D016896:Treatment Outcome