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. 2022 Mar 3:13:26-30.
doi: 10.1016/j.xjtc.2022.02.031. eCollection 2022 Jun.

Aortic valve repair for isolated right coronary leaflet prolapse

Arnar Geirsson  1 , Clarence H Owen  2 , Robert S Binford  3 , Rochus K Voeller  4 , Christopher R Burke  5 , Jeffrey D McNeil  6 , Lawrence M Wei  7 , Vinay Badhwar  7 , J Scott Rankin  7
Affiliations

Aortic valve repair for isolated right coronary leaflet prolapse

Arnar Geirsson et al. JTCVS Tech. .

Abstract

Objectives: Isolated right coronary leaflet prolapse is a common cause of nonaneurysmal aortic insufficiency, but can rarely occur in patients with proximal aortic aneurysms. Standardized techniques for routine autologous repair of this disorder are presented.

Methods: Most aortic valve leaflet prolapse is isolated to the right coronary leaflet, with hypertension and annular dilatation being contributory. Echocardiographically, a posteriorly eccentric aortic insufficiency jet together with "fracture" of the right leaflet tip are diagnostic. Primary repair includes internal geometric ring annuloplasty to downsize and reshape the annulus, together with central plication of the prolapsing leaflet. Thickened, scarred, or retracted noduli are released using an ultrasonic aspirator. The goal is to achieve equivalent coaptation heights of ≥8 mm for all 3 leaflets.

Results: Three videos of 6 cases are provided to illustrate these techniques. In the first, 3 patients are shown with classic isolated right leaflet prolapse. In the second and third videos, alternative pathologies are presented for contrast. Applying the reconstructive approaches of geometric ring annuloplasty, leaflet plication, and ultrasonic nodular release, excellent early and late repair outcomes are obtainable in most patients.

Conclusions: The combination of aortic ring annuloplasty, central leaflet plication, and ultrasonic nodular release allows routine and standardized repair of right coronary leaflet prolapse, either isolated or concomitant with aneurysm surgery.

Keywords: AI, aortic insufficiency; AVr, aortic valve repair; RCP, right coronary leaflet prolapse; aortic ring annuloplasty; aortic valve insufficiency; aortic valve repair.

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Figures

None
Clinical characteristics of isolated right coronary leaflet prolapse.
Figure 1
Figure 1
Because of the elliptical nature of the aortic valve annulus, the right coronary leaflet (RC) has a greater radius of curvature, higher leaflet stress, and hypothetically, a predisposition to “fracture.”
Figure 2
Figure 2
Typical echocardiogram of a patient with isolated right coronary leaflet prolapse showing a “broken” leaflet tip, a leaflet “fracture line,” and a posterior aortic insufficiency (AI) jet.
Figure 3
Figure 3
Typical appearance of isolated right coronary leaflet prolapse with a “broken” leaflet tip and “fracture line.”
Figure 4
Figure 4
After repair, the annulus is reduced from 28 to 21 mm, the right prolapse is corrected with plications, and the noduli coapt centrally. With gentle “pressurization” using 3 closed DeBakey forceps, all 3 leaflets meet in the midline at the same coaptation height.
See this image and copyright information in PMC

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