Aortic valve surgery

Dr. Md. Rezwanul Hoque

MBBS, MS, FCPS, FRCSG, FRCSEd

Associate Professor Department of Cardiac surgery BSMMU, Dhaka, Bangladesh

Aortic valve surgery- history

Year 1955 1956 1960 1967 Procedure Mechanical Aortic valve Dilatation Aortic Homograft valve Ball-valve prosthesisAortic Pulm. Autograft in Aortic position Surgeon Ellis & Kirklin Murray Starr/ Harken Ross

AHA/ACC guidelines 2006

Aortic Stenosis Indicator Jet velocity (m/s) Mean gradient (mm Hg)* Valve area (cm2) Valve area index (cm2/m2) Mild Less than 3.0 Less than 25 Greater than 1.5 Moderate 3.0-4.0 25-40 1.0-1.5 Severe Greater than 4.0 Greater than 40 Less than 1.0 Less than 0.6

Aortic Regurgitation
Mild Qualitative Angiographic grade Color Doppler jet 1+ 2+ 3-4+ Moderate Severe

Central jet, width less than 25% of LVOT

Greater than mild but Central jet, width no signs of severe greater than 65% AR LVOT

Doppler vena contracta width (cm)

Less than 0.3

0.3-0.6

Greater than 0.6

Quantitative (cath or echo)

Regurgitant volume (ml/beat) Regurgitant fraction (%)

Less than 30

30-59

Greater than or equal to 60 Greater than or equal to 50 Greater than or equal to 0.30

Less than 30

30-49 0.10-0.29

Regurgitant orifice Less than 0.10 area (cm2) Additional Essential Criteria

Left ventricular size

Increased

Indications for surgery in aortic regurgitation

European Heart Journal (2007) 28, 230268 doi:10.1093/eurheartj/ehl428

Disease
Severe AR Symptomatic patients (dyspnoea, NYHA class II, III, IV or angina) Asymptomatic patients with resting LVEF 50% Patients undergoing CABG or surgery of ascending aorta, or on another valve Asymptomatic patients with resting LVEF .50% with severe LV dilatation: End-diastolic dimension .70 mm or ESD .50 mm (or .25 mm/m2 BSA) Whatever the severity of AR Patients who have aortic root disease with maximal aortic diameter 45 mm for patients with Marfans syndrome 50 mm for patients with bicuspid valves 55 mm for other patients

Class
IB

IB

IC

IIaC IIaC

IC IIaC IIaC

Indications for aortic valve replacement in aortic stenosis

European Heart Journal (2007) 28, 230268 doi:10.1093/eurheartj/ehl428

Patients with severe AS and any symptoms Patients with severe AS undergoing coronary artery bypass surgery, surgery of the ascending aorta, or on another valve Asymptomatic patients with severe AS and systolic LV dysfunction (LVEF ,50%) unless due to other cause Asymptomatic patients with severe AS and abnormal exercise test showing symptoms on exercise Asymptomatic patients with severe AS and abnormal exercise test showing fall in blood pressure below baseline Patients with moderate AS undergoing coronary artery bypass surgery, surgery of the ascending aorta or another valve Asymptomatic patients with severe AS and moderate-to-severe valve calcification, and a rate of peak velocity progression 0.3 m/s per year AS with low gradient (,40 mmHg) and LV dysfunction with contractile reserve Asymptomatic patients with severe AS and abnormal exercise test showing complex ventricular arrhythmias Asymptomatic patients with severe AS and excessive LV hypertrophy (15 mm) unless this is due to hypertension AS with low gradient (,40 mmHg) and LV dysfunction without contractile reserve

IB

IC
IC IC IIaC IIaC IIaC IIaC IIbC IIbC IIbC

Indications for coronary angiography in patients with valvular heart disease

Before valve surgery in patients with severe VHD and any of the following:
History of coronary artery disease Suspected myocardial ischemia LV systolic dysfunction In men aged over 40 and post-menopausal women 1 Cardiovascular risk factor When coronary artery disease is suspected to be the cause of severe MR (ischaemic MR) European Heart Journal (2007) 28, 230268 doi:10.1093/eurheartj/ehl428

Class 1C

Class 1C

Replacement aortic valves

Tissue valves Autografts, where the patient's own pulmonary valve is dissected out and used to replace the aortic valve; Homografts, where valves are harvested from donor hearts and preserved; Xenografts, which are made of porcine or bovine valvular or pericardial tissue.
Autografts and homografts take the form of an aortic valve, in situ within the intact aortic root, complete with coronary ostia and a fringe of myocardium. Xenografts, which resemble the aortic leaflets in isolation, are usually mounted on a small metal support, or stent but a new generation of stentless bioprostheses are also available.

Mechanical valves Composed of carbon, or occasionally metal alloys, and are classified according to their structure into caged-ball and tilting-disk valves, which may be single or bi-leaflet.

Examples of replacement aortic valves: a) shows an aortic homograft, b) and c) show a xenograft, d) shows a ball and cage valve, e) shows a tilting-disk valve, f) shows a bileaflet valve

Search for a perfect valve

The perfect replacement valve would have a structural lifetime longer than the patient, an intrinsic gradient of 0 mmHg, a haemodynamic profile of the original valve, carry no infective or thrombotic risk, be cheap, readily available and technically easy to insert, and silent.
Over 80 models of prosthetic heart valve have been developed since the 1950s, and the fact that scores are currently in use underlines the fact that no one design fulfills all the criteria of the perfect valve replacement

Mechanical Valves
Mechanical valves are durable, lasting - with the exception of a few rare technical failures - for 20 to 30 years. Their main drawbacks include high transvalvular pressure gradients in the smaller sizes, an abnormal haemodynamic profile, thrombogenicity, infection rates, and haemolysis. A significant minority of patients find that the noise of the functioning mechanical valve is their greatest drawback.

Mechanical valves - contd

In patients with small aortic roots the intrinsic transvalvular gradient for a mechanical valve is higher than that of an equivalently sized bioprosthesis. The effects on the left ventricle of changing the mobile three-dimensional structure of the aortic annulus to a fixed, two-dimensional structure is poorly understood.

Mechanical valves- contd

In an adequately anticoagulated patient (International Normalised Ratio [INR] 2.5-3), the incidence of valve thrombosis is the same as for a bioprosthetic valve: 0.2-5.7% per patient-year. Patients with prosthetic valve thrombosis may present with pulmonary oedema, poor peripheral perfusion and systemic embolisation but, more commonly, the scenario is acute haemodynamic compromise. Thrombi of less than 5 mm that are not obstructing the valve orifice or mechanism may be treated with formal anticoagulation alone but larger thrombi require fibrinolysis or valve replacement.

Tissue vs. mechanical- thromboembolism

Freedom from thromboembolism in patients followed for 20 years. Note that there is no difference in the incidence of thromboembolic events between mechanical and tissue valves.

Khan SS, Trento A, DeRobertis M, et al: Twenty-year comparison of tissue and mechanical valve replacement. J Thorac Cardiovasc Surg 2001; 122:257

Recent trend in anticoagulation

A recent report of patients followed over 25 years noted that approximately 40% of the bleeding episodes occurred in the first year following surgery. It is thus important during this initial postoperative time frame when the patients anticoagulant levels are more likely to fluctuate that INR be measured more frequently. In the early postoperative period, INR can occasionally jump to supratherapeutic levels and result in significant bleeding events. This is an independent risk factor for mortality at 60 days. Furthermore, the most important independent predictor of reduced survival is anticoagulant variability. It is therefore recommended in the early postoperative period that one proceed slowly to bring the INR to target levels while the patient is under the protection of subcutaneous enoxaparin (100 IU/kg twice a day) or heparin (5000 U every 8 hours) until the INR is therapeutic. The addition of aspirin to a warfarin regimen can be expected to result in a lower incidence of TE at any given therapeutic INR with a low probability for bleeding events and so is recommended.
Emery R Wi , Emery A Mi , Knutsen A i , Raikar G Vi . Aortic Valve Replacement with a Mechanical Cardiac Valve Prosthesis. Cohn Lh, ed. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2008:841-856.

Mechanical valves- Risk of Endocarditis

Mechanical valves may be at higher risk of infection than tissue valves during the first three post-operative months but infection rates converge and are similar at five years.
The risk of a prosthetic valve infection is up to 3.1% at one year and 5.7% at five years. Skin commensals such as Staphylococcus epidermidis and S. aureus are usually identified as the cause of peri-operative prosthetic endocarditis - associated mortality is between 30 and 80%. Late prosthetic endocarditis, which is caused by the same organisms that are responsible for native valve endocarditis, i.e. streptococci, has an associated mortality of between 20 and 40%.

Significant Failures
Mechanical
Bjork-Shiley Duromedics

Abrams Valve

Tissue Valves
Some 10-20% of homograft and 30% of xenograft valve replacements fail within 10-15 years of implantation and require replacement. Tissue valves last longer in the elderly population because the haemodynamic demands on the valve are less: the freedom from operation for homograft valve failure is 47% in patients aged 0-20 years, 85% in the 21-60 years age group, and 94% in patients aged over 60 years of age. Tissue valves last much longer in the aortic position compared to the mitral (the mitral valve must remain closed against peak ventricular systolic pressures, whereas the aortic valve opens passively during ventricular systole).

SJM epic valve implantation

Tissue valves- contd

Tissue valves are far less thrombogenic than mechanical valves and anticoagulation is not required. Unless an elderly patient is already undergoing anticoagulation for some pre-existing condition, a tissue valve would be the prosthesis of choice as it affords 10-15 years of warfarin-free life. Similarly, in patients with bleeding diathesis, who could not be maintained safely on warfarin, most surgeons would select a bioprosthesis over a mechanical valve replacement.

Pregnant women have an increased risk of prosthetic valve-related thromboembolic complications and adequate anticoagulant therapy is particularly important in this group if a mechanical valve has been implanted. Warfarin is contraindicated during the first trimester as it is teratogenic - twicedaily subcutaneous heparin or intravenous heparin should be administered instead of warfarin from initial attempts to conceive up until either the beginning of the second trimester or until delivery.
The understandable preference of many women is, therefore, for a bioprosthetic valve. Where the expertise is available, a homograft, which offers the longest lifespan, may be the preferred option.

Freedom from all valve-related complications over 20 years. Note that in the first 10-year period of follow-up, complications related to mechanical valves exceeded those of tissue valves. The lines cross at approximately 10 years, and over the following period, complications from tissue valves were more frequent than those from mechanical valves.
Khan SS, Trento A, DeRobertis M, et al: Twenty-year comparison of tissue and mechanical valve replacement. J Thorac Cardiovasc Surg 2001; 122:257

Single Layer Stentless

Bioprosthetic Problem Solving

Early
Calcification

Later valves
Tissue engineering (composite valves / muscle bar) Zero pressure fixation Anti-calcification remedies Blue valves (toluidine blue)

Recent Valves
Sorin Valves (amino acids)

Significant Bioprosthetic Failures

Dura Mater abandoned Fascia Lata abandoned Ionescu-Shiley abandoned Autogenics - abandoned

Mechanism of failure
Biological gradual failure Mechanical catastrophic

Homografts
Homografts carry a small risk of infection linked to donor and storage mechanisms, although this is offset many times over by their low susceptibility to post-operative prosthetic endocarditis. As a result, these are the valve replacement of choice in fulminant bacterial endocarditis. The increased longevity and reduced incidence of prosthetic endocarditis in homografts compared to xenograft valves begs the question of why they are not more frequently used. Harvesting, selecting and preparing homografts requires a degree of expertise and resources that are not available to many centres. Implantation is technically more demanding, requiring experience in positioning the homograft in the correct anatomical position, dissecting out the coronary ostia and re-implanting them, and additional suture lines. All of these carry an increased risk of post-operative bleeding and prolong the time for which the patient is on bypass, leading to an increased post-operative incidence of renal failure, pulmonary dysfunction, myocardial dysfunction and neurological sequelae. In inexperienced hands, early and late complications render this a less favourable option.

Pulmonary Autograft Using the patient's own pulmonary valve to replace the aortic valve is known as the Ross procedure, after Sir Donald Ross, the British surgeon who pioneered its use. The pulmonary valve is replaced with a pulmonary homograft, which has a life expectancy of 20-30 years.

The patient's own pulmonary valve in the aortic position has a similar life expectancy, is resistant to infection and does not warrant formal anticoagulation.
The drawbacks are primarily related to the technical difficulty of both procedure and reoperation.

Ross procedure

Ross procedure( contd)

Step 5: A pulmonary homograft is attached to the right ventricle outflow tract.

Operative Risk
The operative mortality associated with aortic valve replacement varies between 2% for an otherwise fit patient in the elective setting, to over 30% for a combined or emergency procedure in a patient with multiple co-morbidity. The EuroSCORE system is one of a number of scoring systems derived from studies of large populations of patients. With the knowledge of 12 clinical variables such as age, sex, serum creatinine and left ventricular dysfunction, a percentage operative risk can be quoted for that patient, which has been shown to be accurate in all but the highest risk cases where mortality is generally underestimated. The best operative mortality for aortic stenosis according to EuroSCORE would be approximately 3%. UK registry data give the mortality for isolated aortic valve replacement at 2.2% for mechanical valves, 4% for bioprosthetic valves and 5% for homograft replacement. This may reflect the higher proportion of young, low-risk patients undergoing mechanical valve replacement. Surgeon-specific data in the UK suggest that variability between individual surgeons accounts for less than 0.4%. The operative risk of a mechanical valve replacement is similar to that for a tissue valve. The Ross procedure carries an increased risk of up to 7.4%. It is also apparent from EuroSCORE that concomitant coronary artery bypass grafting caries a substantial additional risk.

Post-operative complication
The risk of stroke (because of emboli from the calcified valve, the aortic cannulation site, hypoperfusion or haemorrhage) is 3% in patients without other risk factors for cerebrovascular events. In addition to the problems with post-operative management described above, patients are warned that aortic valve replacement carries a risk of conduction abnormalities requiring antidysrhythmics, or occasionally permanent pacemaker insertion. The other main peri-operative complications are - as for any open heart surgery - chest infection, pleural effusion, post-operative haemorrhage requiring resternotomy, wound infection which may require further surgery, and acute renal failure.

Minimally Invasive Valve Replacement

Percutaneous peripheral cannulation TAVI/TAVR Heartport techniques Mini-sternotomy Mini anterior thoracotomy Surgery under epidural anaesthesia

Minimally invasive aortic valve replacement

Partial upper sternotomy results in excellent exposure and a safe conduct of a variety of operations on the aortic valve and ascending aorta. The sternotomy extends into the right fourth intercostal space and is performed through an 810 cm long skin incision. The pericardium is opened in the midline and aorta and right atrium are cannulated directly. Aortic valve is exposed through the oblique aortotomy, after placement of retraction sutures to the commissures. The procedure is performed with the usual surgical instrumentation and can therefore be easily adopted.

Minimal Access AVR

Minimal Access Aortic Root

Minimally Invasive vs. Conventional Valve Replacement

Overall majority of reported results similar Death Length of stay Complication rates Minor negative aspects of: Longer X clamp times Longer bypass times Increased early post-operative pain Some reports of improved outcome with keyhole approach Lower risk redo operations Aortic vascular procedures Lower transfusion requirements Lower incidence post-operative AF Lower post-operative pain after day 2

Difficult Valve excision

Small annulus
Good exposure from retraction sutures Position light and table Enthusiastic excision / decalcification Do not oversize valve Consider supra-annular placement Do NOT use everting mattress sutures (Root enlargement)

Aortic valve replacement in small aortic root

Supra-annular placement of the aortic valve prosthesis is primarily used in small aortic annulus to prevent a patient-prosthesis mismatch. The most important surgical steps are: careful removal of the diseased valve including annular decalcification; assessment of the prosthesis seating to guarantee free movement of leaflets and to prevent obstruction of coronary orifices; implantation with interrupted stitches placed infra-annularly, with the prosthesis being seated in a supra-annular position. If necessary, a sub-annular resection of asymmetric septal hypertrophy should be carried out prior to placement of the prosthesis.

Aortic Root Enlargement Procedures

Aortic root enlargement procedures are important techniques to be applied in the small aortic root. The root can be enlarged anteriorly by Konno-Rastan aortoventriculoplasty. This was extensively used but there are some significant problems with the operation and it has largely been abandoned in favor of the Ross procedure with anterior enlargement (Ross-Konno procedure). Most root enlargement procedures are performed posteriorly in adult patients. Incision into the posterior commissure is the most anatomically correct of these procedures. Operating time is increased but not at the expense of increased morbidity or mortality. The Konno procedure is historical, and the Nicks procedure with incision of the posterior commissure is the best anatomically of the posterior enlarging procedures. The Konno procedure involves a deep incision of the infundibular septum which can divide the first septal artery. The reconstruction is complex involving two patches to reconstruct the left ventricular outflow tract and the right ventricle while implanting a large prosthetic valve.

Aortic Root Enlargement Procedures-contd The Nicks operation involves extending the aortotomy into the posterior commissure. The incision enters the interleaflet triangle. The loose tissues of the triangle separate readily so that the annulus may enlarge sufficiently without incision of the anterior leaflet of the mitral valve or entering the left atrium. A prosthetic patch is placed into the posterior commissure and the noncoronary sinus to accommodate a prosthesis perhaps 2 or 3 mm larger than the original annulus. When enlargement more than 2 or 3 mm is required, it is necessary to extend the incision across the mitral annulus into the anterior leaflet of the mitral valve to allow the tissues to separate further at the annulus. A prosthetic patch is used to close the defect and enlarge the left ventricular outflow tract. The patch is attached to the anterior leaflet of the mitral valve with interrupted stitches. While it is tempting to use a simple running stitch, the interrupted stitch method distributes suture tension more evenly in order to prevent dehiscence of the patch from leaflet tissues A larger prosthetic valve may then be accommodated in the left ventricular outflow tract.

Supra-annular placement of aortic valve prosthesis

In 1978 Rahimtoola coined the term patient-prosthesis mismatch to describe the condition where an impediment to the blood outflow in patients with small aortic prosthesis results in incomplete regression of the left ventricular hypertrophy, with residual symptoms and possibly a decreased life expectancy. As a lower level of acceptable valve opening area a value of 0.85cm2/m2 is generally acknowledged. The original idea of supra-annular placement of the valve prosthesis was described and patented by Carpentier in 1981. By placing the valve prosthesis above the annulus, the narrowing of the left ventricular outflow by the sewing ring of the prosthesis is minimized, resulting in improved hemodynamic performance . Some newer mechanical prosthetic valves are designed for supra-annular placement, to be used in a narrow aortic orifice with a diameter below 2123 mm . This procedure depicts the replacement of the stenotic aortic valve with Regent SJM prosthesis .

Supra annular placement of aortic valve

Difference between intra- and supraannular placement of the aortic valve prosthesis, by courtesy of Carbomedics. Infra-annularly placed, pledgetted noneverting mattress sutures, by courtesy of Carbomedics.

Supra annular placement of aortic valve

Schematic implantation technique with interrupted non-everting mattress, by Courtesy of Sorin 3.

Supra-annular seating of the prosthesis, by Courtesy of Sorin.

Sorins Sutureless Perceval S Aortic Valve

Unlike traditional heart valve replacements, the Perceval S is selfanchoring, which means that it does not need to be sutured into place. Because no sutures are required, using the Perceval S results in reduced procedure time for aortic valve replacements.

Percutaneous/Transcatheter aortic valve replacement(TAVI/TAVR)

The Cribier-Edwards Percutaneous valve (Edwards Lifesciences, Irvine, Cal, USA) is a bioprosthesis made of three leaflets of equine pericardium sutured to a balloon expandable stainless steel stent. After balloon predilatation of the native valve, this bioprosthesis is crimped over a balloon catheter, and advanced over a stiff guidewire through the vessels (either from the femoral vein -antegrade/transseptal approach- or the femoral artery -retrograde approach-) up to the diseased fibro-calcific native aortic valve, using regular cardiac catheterization techniques. The bioprosthesis is then released by balloon inflation at mid-part of the native valve. .

Result of TAVI
In high-risk patients with severe aortic stenosis, transcatheter and surgical procedures for aortic-valve replacement had similar rates of survival at 1 year, although there were important differences in risks associated with the procedure. The transcatheter procedure was associated with a higher risk of stroke than the surgical replacement (5.5% vs. 2.4% after 30 days; 8.3% vs. 4.3% after 1 year). In 2010 good results (20% better 1 year survival) were reported from a US trial on 358 patients. The procedure was called transcatheter aorticvalve implantation (TAVI) and implanted cow heart valves.
Schaff, Hartzell V. (June 2, 2011). Transcatheter aortic valve implantation-at what price? N Engl J Med 364: 22562258.

TAVI- SAPIEN device (a balloon-expandable tubular metal stent with a tri-leaflet valve fashioned out of bovine percardium mounted within).

Valve for TAVI/TAVR

Aortic valve repair

Aortic valve repair is nearly exclusively limited to patients with aortic regurgitation (AR) without a component of stenosis. Patients considered for repair are generally young who wish to avoid anticoagulation and would be expected to outlive a tissue valve should replacement be considered.

In order to perform this operation, the cusps must be thin and flexible without calcifications.
Most repairs result in downsizing the effective orifice area in order to increase coaptation with the available cusp area. There is a resultant increase in aortic valve gradient and this must be anticipated when evaluating patients preoperatively. The decision to repair an aortic valve is made by weighing the risk of repair failure versus the benefit of avoidance of oral anticoagulation therapy.

Aortic valve repair

Aortic valve repair is most commonly performed in patients with aortic regurgitation caused by Dilated aortic annulus Conjoined cusp prolapse in bicuspid aortic valves (BAV) Single cusp prolapse in tricuspid aortic valves, Aortic valve cusp perforation from endocarditis Various techniques required for these regurgitant lesions are used to create competency in aortic valve with their geometry affected by type A aortic dissection, aortic root and ascending aortic aneurysms, and ventricular septal defects. Aortic valve repair is performed in two general settings: patients who present with severe AR as their primary indication for surgery patients with another cardiac problem as the indication for surgery who are found to have concomitant AR.

Annular Dilation 1. This type of AR is caused by a dilated aortic annulus resulting in a sagging of the belly of the cusp resulting in lack of central cusp apposition. Reduction annuloplasty corrects the problem by increasing the surface area of cusp coaptation. 2. The subcommissural triangles are closed by horizontal mattress sutures (4-0 polypropylene) reinforced with teflon pledgets 3. Dilators can be used to assess the annulus diameter following commissural plication. 4. The sinotubular junction is often slightly dilated in these patients. This splaying outwardly of the commissural posts contributes to central AR. Repair requires either plication above the commissures or circumferential downsizing of the sinotubular junction by replacing an enlarged ascending aorta with an appropriately sized Dacron tube graft. This tube graft diameter should be 10-15% smaller than the measured annular diameter.

Illustration demonstrating pledgeted commissuroplasty.

Intraoperative photograph prior to repair. Note: loss of cusp coaptation. The pledgeted sutures are stay sutures for improved exposure.

Intraoperative photograph following pledgeted commissuroplasty.

Bicuspid Aortic Valve 1. This type of AR results from the prolapse of the conjoint cusp. The usual conjoint cusp is a fusion of the right and left coronary cusps. The goal of the correction is to shorten the redundant conjoint cusp thus elevating the free margin of the cusp to coapt with the other non-prolapsing cusp. 2. The redundant free margin in triangularly resected in the central fused raphe portion. The resection is not continued to the annulus. The apex of the triangle is ended midway to the annulus where the valve cusp tissue remains thickened. 3. The cut edges of the cusp are reapproximated using 5-0 or 6-0 polypropylene suture in an interrupted fashion. 4. Often the raphe is tethered to the aortic wall by a residual commissure. This band of tissue can tether the conjoint cusp away from the center of the aortic orifice. The band should be cut releasing the central portion of the conjoint cusp and deepening the belly of the cusp. The cut to sever the tethering raphe band can be carried into the aortic wall to avoid perforating the thin portion of the cusp where it attaches to the adjacent annulus. 5. Occasionally, the non-conjoint cusp requires slight shortening with a plication suture (6-0 polypropylene suture) to adjust it to the newly repaired conjoint cusp. 6. The two subcommissural triangles are then closed as previously described.

Illustration demonstrating bicuspid valve with conjoint cusp prolapse and subsequent shortening.

Intraoperative photograph after resection of a central triangle of redundant prolapsing conjoint cusp. The first interrupted suture reapproximating the cut edges of the cusp is being placed.

Intraoperative photograph demonstrating the completed interrupted sutureline. The raphe has been resected.

Intraoperative photograph demonstrating pledgeted commissuroplasty.

Intraoperative photograph demonstrating completed repair, shortened cusp and commissuroplasty at each commissure.

Cusp Prolapse in Tricuspid Valve 1. This type of AR is caused by the prolapse of one or more cusps. The free margin is elongated. This can occur by rupture of a small fenestration. The goal of this repair is to shorten the free margin to meet the other cusps. 2. There are different ways to repair this defect: a. As described by Trusler, the prolapsed cusp can be plicated near the commissure with 5/0 polypropylene suture. b. The prolapsed cusp can be resuspended by performing a limited triangular resection in the center of the cusp with reapproximation of the cut edges of the cusp with interrupted 6-0 polypropylene sutures. c. The free edge can be shortened by weaving a 5-0 PTFE suture along the free edge of the cusp and anchoring it to the commissure. The three subcommissural triangles are then closed as previously described.

Intraoperative photograph demonstrating completed repair of cusp prolapse in tricuspid valve. Repair was performed by plicating prolapsed cusp and pledgeted commissuroplasty. Note: 6-0 polypropylene plication suture next to the node of Arantis.

Cusp Perforation
1. This type of AR is caused by infective endocarditis or iatrogenic perforation. The goal of this repair is to patch the defect in the cusp. 2. An autologous pericardial patch is prepared and used to cover the defect with either running or interrupted 6-0 polypropylene suture. Avoid the urge to close this defect primarily. This results in retraction of the free margin and loss of coaptation.

Illustration demonstrating cusp perforation and subsequent patch repair.

Intraoperative photograph demonstrating cusp perforation prior to repair.

Intraoperative photograph following patch repair of cusp perforation with non-fixed autologous pericardium.

Concluding Tips
Saline can be used to fill the cusps to estimate apposition of the cusps. 1. The aortotomy is closed with a running 4-0 polypropylene suture over and over in a double layer with Teflon felt pledgets at both ends to buttress the suture line. In the case of complete transection of the aorta a continuous running 4-0 polypropylene suture is used. The cross clamp is removed. The heart is de-aired and the patient weaned from cardiopulmonary bypass. 2. Intraoperative transesophageal echocardiography is used to assess the adequacy of the repair.

Result of aortic valve repair- subvalvular circular annuloplasty Between January 1994 and June 2001, aortic valve repair was performed in 40 patients (eight females, 32 males; mean age 61.0 10.5 years) of this type. Survival was 94.9% at one year and 82.6% at five years. The fiveyear reoperation-free rate was 87%.

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