Aortic valve reconstruction: current status

Abstract

Whereas aortic valve replacement (AVR) is an effective treatment for aortic stenosis, aortic valve repair (AVr) is an excellent alternative to AVR for aortic insufficiency (AI). The advantages of AVr include a lower risk of infective endocarditis, plus avoidance of typical complications associated with mechanical valves (i.e., thromboembolic and hemorrhagic complications) and bioprostheses (i.e., structural valve deterioration). However, AVr is technically more demanding, surgical techniques vary from center to center, and outcomes are variable. As experience accrues, the indications for AVr continue to expand in some centers. Careful preoperative evaluation and intraoperative transesophageal echocardiography (TEE) are necessary for proper patient selection. The ideal patient is young or middle-aged, does not require multiple concomitant cardiac procedures, has a dilated aortic sinotubular junction (STJ) and/or root, and pliable AV cusps. A standardized pathology- directed approach helps achieve reproducible outcomes. A dilated ascending aorta/STJ is treated with simple replacement of the ascending aorta with plication of the STJ. Dilated aortic sinuses of Valsalva are treated with a valve-sparing root replacement, either a David reimplantation or a Yacoub remodeling procedure. Aortic cusp pathology may be treated with cusp plication, triangular resection, or patch closure of perforations. The dilated aortic annulus and Marfan's syndrome patients are optimally treated with a David procedure.The perioperative results significantly influence long-term outcomes, emphasizing the importance of postrepair TEE. Using a standardized approach with careful patient selection, an 85-95% survival, a 90-95% freedom from reoperation, and an 80-90% freedom from moderate to severe AI may be expected at 8-10 years postoperatively.