title: Aortic valve reimplantation for large root aneurysm and high-grade aortic regurgitation: incidence and implications of additional cusp and commissure repair.
abstract: OBJECTIVE
  Large-sized root aneurysm and high-grade aortic regurgitation (AR) might be contraindications for a valve-sparing aortic root replacement procedure (V-SARR) and aortic valve repair. The impact of a combination of root reimplantation and additional cusp/commissure repair on valve sufficiency in this setting was investigated with respect to early- and mid-term functional outcome.
  
  
  METHODS
  Out of a cohort of 220 patients treated with V-SARR, 73 with an aneurysm size ≥ 55 mm were identified. As a cut-off for high-grade preoperative AR, a grade of ≥ 3 was defined. End points were absolute early and mid-term aortic regurgitation grades, new incidence of AR and AR progression. The mean echocardiographic follow-up time was 3.8 years. T-tests, Kaplan-Meier and log-rank calculations were employed.
  
  
  RESULTS
  Within the studied cohort of large aneurysms ≥ 55 mm [total, n = 73; mean age, 56 ± 14 years; female, n = 22 (30%); Marfan, n = 9 (12%); bicuspid valve n = 6 (8%)], 21 (29%) individuals had AR grades ≥ 3+. The rest had lower grade AR (63%) and 6 (8%) had a normally functioning aortic valve. The incidence rate of additional cusp procedures was 27% (n = 20) and included cusp plication, Trussler Stitch, cusp shaving and commissure resuspension. Incidence of additional cusp/commissure repair was 2 (9.5%) among patients with higher grade AR ≥ 3+, while it was 18 (30%) among patients with lower grade AR or a normally functioning valve (P = 0.03). The mean early postoperative AR was 0.5 (median, 1.0). The rate of freedom from early failure, valve replacement and AR ≥ 2 was 96%. The rate of freedom from AR progression was 96% and from new onset AR was 100%.
  
  
  CONCLUSIONS
  The setting of a large proximal thoracic aortic aneurysm size and high-grade AR does not result in a higher need for cusp/commissure procedures in order to achieve a satisfactory mid-term functional outcome. Large aneurysm size and high-grade AR per se do not increase the complexity of repair. The choice of reimplantation technique and prosthesis size selection might impact on mid-term valve function.
authors.affiliation: Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany fabian.alexander.kari@universitaets-herzzentrum.de.
authors.forename: Fabian A
authors.initials: FA
authors.lastname: Kari
authors.affiliation: Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Siepe
authors.affiliation: Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany.
authors.forename: Bartosz
authors.initials: B
authors.lastname: Rylski
authors.affiliation: Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany.
authors.forename: Sami
authors.initials: S
authors.lastname: Kueri
authors.affiliation: Cardiovascular Surgery, University Heart Center Freiburg, Freiburg, Germany.
authors.forename: Friedhelm
authors.initials: F
authors.lastname: Beyersdorf
mesh_terms: D000328:Adult; D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001021:Aortic Valve / Q000473:pathology / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D058385:Cardiac Valve Annuloplasty / Q000379:methods* / Q000401:mortality; D002423:Cause of Death; D015331:Cohort Studies; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012092:Replantation / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D015996:Survival Rate; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods
keywords: Aortic aneurysm; Aortic valve; Heart valve repair; Valve-sparing aortic root replacement