Assessment and Repair of Aortic Valve Cusp Prolapse: Implications ...

Assessment and Repair of Aortic Valve
Cusp Prolapse: Implications for Valve
Sparing Procedures
Munir Boodhwani 1,2 , Laurent de Kerchove 1 , Christine Watremez 1 , David Glineur 1 ,
Jean Rubay 1 , Robert Verhelst 1 , Philippe Noirhomme 1 , Gebrine El Khoury 1
1
Department of Cardiovascular and Thoracic Surgery, St. Luc Hospital - Brussels,
Belgium
2
Division of Cardiac Surgery, University of Ottawa Heart Institute
Ottawa, Canada
American Association of Thoracic Surgery
90 th Annual Meeting – Toronto, Ontario, Canada
May 3 rd , 2010

The authors have no conflicts of interest to
disclose

Aortic Cusp Prolapse
• Cusp prolapse in trileaflet aortic valves is an
infrequent cause for isolated aortic insufficiency
– Shapiro et al. found an prevalence of 1.2% in a crosssectional
review of 2000 echocardiograms
• Most patients with isolated cusp prolapse
currently undergo aortic valve replacement:
– Unfamiliarity with diagnosis and assessment
– Repair techniques
– Lack of long-term outcome data

AV Sparing Surgery
• Lack of recognition and treatment of cusp
prolapse is an important reason for early and
late failure of valve sparing operations
• Cusp prolapse may be pre-existing, unmasked,
or induced during AV sparing surgery
• Questions:
– Will there be a need for cusp prolapse repair?
– Which cusp(s) will need repair?
– How much correction will be required?

Aims
• To examine clinical, echocardiographic, and intraoperative
characteristics of patients with isolated cusp prolapse and
with associated ascending aortic disease
• To compare outcomes following aortic valve repair for
cusp prolapse

Patient Population
Patients undergoing
AV Repair
(n = 428)
Trileaflet AV
(n = 111)
excluded
excluded
No Cusp Prolapse Repair
(n = 234)
Methods:
• Review of prospectively collected surgical data
Cusp Prolapse Repair
• Blinded review of preoperative Echocardiograms in all patients
(n = 194)
• Clinical and Echocardiographic follow-up
Non-trileaflet AV
(n = 83)
– 100% complete
– Mean follow-up: 3.8 years [range – 0.1 – 13.3 years]
Isolated Group
(n = 50)
Associated Group
(n = 61)

Aortic Cusp Prolapse - Diagnosis
• Echocardiography
– Different levels of cusp free margin
– Low coaptation height
– Eccentric AI Jet (not perpendicular
to LVOT)
– Excess cusp tissue (SAX view)
– Fibrous band on prolapsing cusp

Fibrous Band

Pathophysiology of Cusp Prolapse
• Cusp prolapse is associated with excess cusp motion
Cusp Motion = Free Margin Length (FML)
Insertion Length (IL)

Repair Techniques
Free Margin Plication
• Quick
• Efficient
• Minimal Foreign
material
Isolated: 37%
Associated: 48%
Boodhwani M, El Khoury G JTCVS 2010;139(4):1075-7.

Repair Techniques
Free Margin Resuspension
• Fragile Free Margin
• Close Fenestrations
• Homogenize free margin
Isolated: 33%
Associated: 32%
Plication + Resuspension
Isolated: 22%
Associated: 17%
Boodhwani, El Khoury G Op Tech Thoracic Cardiovasc Surg 2010 .

Technical Adjuncts
• Two cusp prolapse
– Non-prolapsing cusp serves as reference
• Three cusp prolapse
– Rare
– Seen with AV sparing surgery
– Restore coaptation height to mid-level of sinuses of
Valsalva

Clinical Characteristics
Characteristic
Isolated
(n=50)
Associated
(n=61)
p-value
Age 57 16 56 17 0.68
Male 46 (92%) 57 (92%) 0.97
NYHA Class
I
II
III
13 (26%)
27 (54%)
10 (20%)
31 (51%)
26 (43%)
4 (7%)
0.01
LV Ejection Fraction < 50% 12 (24%) 4 (7%) 0.008
Previous Cardiac Surgery 6 (12%) 8 (13%) 0.86
LVEDD (mm) 62 9 59 8 0.05
Aortic Size (mm) - 51 7 -
Concomitant Procedures
CABG
Mitral valve repair/replacement
Other
23 (46%)
11 (22%)
12 (24%)
6 (12%)
15 (25%)
8 (13%)
6 (10%)
2 (3%)
0.02

Echocardiographic Features
AI Severity
1+
2+
3+ or 4+
Characteristic
Isolated
(n=50)
0
10 (20%)
40 (80%)
Associated
(n=61)
10 (16%)
16 (26%)
35 (57%)
p-value
0.005
Eccentric Jet 40 (83%) 34 (63%) 0.02
Fibrous Band 32 (67%) 20 (34%) 0.001
Cusp Prolapse 41 (85%) 38 (66%) 0.02

Echocardiographic Features
Characteristic Sensitivity Specificity
Eccentric Jet 92% 96%
Fibrous Band 57% 92%
Fibrous band correctly identified the prolapsing cusp in all cases

Intraoperative Data
Characteristic
Isolated
(n=50)
Associated
(n=61)
p-value
Number of cusps repaired
One cusp
Two cusp
Three cusp
36 (72%)
13 (26%)
1 (2%)
47 (77%)
10 (16%)
4 (7%)
0.27
Cusps Repaired
Right Coronary Cusp
Non Coronary Cusp
Left Coronary Cusp
35 (70%)
21 (42%)
9 (18%)
40 (66%)
17 (28%)
22 (36%)
0.62
0.12
0.03
Aortic Annulus Interventions
Sub-Commissural Annuloplasty
Valve-sparing root replacement
Reimplantation Technique
Remodelling Technique
Supra Coronary Aortic replacement
46 (92%)
-
-
-
13 (21%)
49 (80%)
2 (3%)
11 (18%)
-

Early Outomes
• No hospital mortality
• No early AV reintervention
• Permanent Pacemaker – 3.6%
• Post-repair Echo
– AI grade 0 or 1+ : 95%
– AI grade 2+ : 5%

Percent survival
Overall Survival
100
80
60
40
20
Isolated
Associated
8 years
88 12%
82 9%
0
0 2 4 6 8 10
No. at risk
Years
Isolated 50 43 30 18 11 7
Associated 61 56 35 17 7 4

%
Freedom from Cardiac Death
100
80
60
40
Isolated
Associated
8 years
88 12%
97 3%
20
0
0 2 4 6 8 10
No. at risk
Years
Isolated 50 43 30 18 11 7
Associated 61 56 35 17 7 4

%
Freedom from AV Reoperation
100
80
60
40
Isolated
Associated
8 years
100%
93 4%
20
0
0 2 4 6 8 10
No. at risk
Years
Isolated 50 43 30 18 11 7
Associated 61 56 35 17 7 4

%
Freedom from Recurrent AI > 2+
100
80
60
8 years
40
20
Isolated
Associated
87 7%
93 5%
0
0 2 4 6 8
No. at risk
Years
Isolated 50 30 18 9 6
Associated 61 40 22 7 5

%
Freedom from Thromboembolism, Bleeding,
and Endocarditis
100
80
60
8 years
40
98 2%
20
0
0 2 4 6 8 10
Years
No. at risk 111 78 49 23 9 3

Subgroup Analysis
• Number of cusps repaired (single vs. multiple)
did not affect AV reoperation or AI recurrence
(p = 0.25)
• Choice of surgical technique (Plication vs.
Resuspension vs. Both) did not affect repair
durability (p = 0.6)

Conclusions
• Isolated cusp prolapse causing AI is a distinct
clinical entity with unique echocardiographic and
intraoperative features
• Cusp prolapse is repairable with or without
ascending aortic disease and leads to durable
outcome and low risk of valve related
complications (0.47%/person-yr)

Implications for AV Sparing Surgery
• Eccentric AI jet is highly sensitive and specific for the
diagnosis of pre-existing cusp prolapse and predicts the
need for repair in the majority (63%) of patients
• A fibrous band is specific (92%) for cusp prolapse and
can help to localize the prolapsing cusp
• Intraoperative assessment is critical for the diagnosis of
unmasked or induced cusp prolapse.

Thank You

Discussion Slides

%
AV Sparing alone vs Sparing +AV repair
Freedom from AI >2+
100
80
60
logrank test:
p=0.8
40
20
Sparing alone
Sparing +AV repair
0
0 24 48 72 96 120
Months
patients at risk :
Sparing 74 45 35 25 17 9
Sparing+Repair 90 51 21 7 5 3

Predictors of Recurrent AI
• Restoration of valve geometry is critical
– Length and height of coaptation

Intraoperative Data
Characteristic
Isolated
(n=50)
Associated
(n=61)
p-value
Cardiac Ischemia Time (min) 72 33 113 31

STJ – Sino-tubular Junction; SCA – Sub-Commissural Annuloplasty Boodhwani et al., JTCVS 2009;137:286-94