Aortic Valve Repair for Severe Commissural Leaflet Defects Using Aortic Wall Patches

Abstract

Background: In patients with aortic insufficiency, annular dilatation often accompanies valve incompetence, necessitating annuloplasty. However, primary leaflet defects also are common, and when found unexpectedly at the time of planned repair, inadequate leaflet tissue often prompts prosthetic valve replacement. A method for achieving stable repair for severe leaflet deficiencies would be useful.

Methods: In this report, major leaflet defects due to ruptured large fenestrations were encountered in 2 patients, the first repaired with extensive plication, which failed. In the second patient, the defect was reconstructed using an autologous aortic wall patch. After geometric annuloplasty, the aortic wall strip was sutured with interrupted 6-0 sutures from the nodulus to the commissural top, with the intima facing coaptation. Leaflet free-edge length was adjusted to match the other normal leaflets at approximately reconstructed annular diameter x 1.5.

Results: In the aortic wall patch patient, grade 4 preoperative aortic insufficiency fell to zero after repair, and the patient is doing well with continued excellent echo parameters at 1 year postoperatively.

Conclusions: As a leaflet substitute during aortic valve repair, aortic wall patches seem to provide an excellent solution to managing severe leaflet deficiencies.

Figure 1

Comparison of “normal” annular diameter predicted from leaflet free-edge length and pathologic annular diameter assessed with Hegar dilators in 74 patients with chronic aortic insufficiency (AI). Measured annular diameter was enlarged to some extent in every patient. The 95% covariate confidence ellipse of mean values did not intersect the line of identity, indicating significant annular dilatation (minor axis standard error of the mean [SEM] vector) in most patients with chronic AI. Average pathologic dilatation (y-axis of ellipse center vs line of identity) was 4.9 ± 2.1 mm. Modified from Jasinski and associates.

Figure 2

Echocardiographic and video views of valve for patient 2 showing severe posterior aortic insufficiency (A) from ruptured right coronary fenestration (B). After repair, valve was fully competent (C) with strip of aortic wall sutured into the right leaflet and commissure (D).