Use of aortic wall patches as leaflet replacement material during aortic valve repair

Abstract

Objectives: Aortic valve repair can be limited by inadequate leaflet tissue for proper coaptation. Various kinds of pericardium have been used for cusp augmentation, but most have failed because of tissue degeneration. A more durable leaflet substitute is needed.

Methods: In this report, 8 consecutive cases are presented in which autologous ascending aortic tissue was used to augment inadequate native cusps during aortic valve repair. Biologically, aortic wall is a living autologous tissue that could have exceptional durability as a leaflet substitute. Techniques for insertion are described in detail, along with procedural videos.

Results: Early surgical outcomes were excellent, with no operative mortalities or complications, and all valves were competent with low valve gradients. Patient follow-up and echocardiograms to a maximum of 8 months' postrepair remain excellent.

Conclusions: Because of superior biologic characteristics, aortic wall has the potential to provide a better leaflet substitute during aortic valve repair and to expand patient categories amenable to autologous reconstruction. More experience and follow-up should be generated.

Keywords: aortic leaflet replacement; aortic valve repair; leaflet defects.

Graphical abstract

Aortic wall patching of a calcified raphe defect during bicuspid aortic valve repair.

Figure 1

Illustrations from patients 1, 2, and 4 receiving aortic wall patches during complex aortic valve repair. The first patient had a torn right-/noncoronary commissure from balloon valvuloplasty of a unicuspid valve in childhood (A), with inadequate fused and nonfused cusp tissue for repair. Patches of ascending aorta were placed into both leaflets, using interrupted 6-0 PROLENE sutures (Ethicon; dark blue arrows). After repair, the leaflets opened well (B), with excellent coaptation height (C). In the second unicuspid patient, the repair was started with a right-/noncoronary commissurotomy, but the left-/right coronary raphe contained a broad transmural mass of calcium. The calcified raphe and cleft tissue were resected and replaced with a patch of aortic wall tissue (D, dark blue arrow). Postrepair, the valve opened and coapted well (E and F). The third patient had a quadricuspid truncus valve with a deficient left coronary leaflet. The defect was patched with aortic wall (G), and after repair, valve opening and coaptation were excellent (H and I). UAV, Unicuspid valve; Quad, quadricuspid valve. Light blue arrows show the leaflets open, and green arrows depict the closed, coapted leaflets.

Figure 2

Graphical abstract. UAV, Unicuspid valve; BAV, bicuspid aortic valve.