Diana Aicher, Frank Langer, Oliver Adam, Dietmar Tscholl, Henning Lausberg, Hans-Joachim Schäfers; Department of Thoracic- and Cardiovascular Surgery, University-Hospital Homburg/ Saar, Germany, Homburg, Germany
Objective: Cusp prolapse may be an isolated cause of aortic regurgitation, it may also be present in conjunction with dilatation of the proximal aorta. Prolapse may be corrected by central plication (CP) of the free margin or triangular resection (TR). In the presence of calcification or fenestration, pericardium (PP) can be added for cusp repair. We retrospectively analyzed our results with these techniques.Methods: From 10/1995 to 10/2006, 561 patients (age 3-86) underwent aortic valve (AV) repair, of which prolapse (no retraction or endocarditis) was found in 399. Prolapse was defined by a relative difference in height of the free margins, in the last 100 cases by height difference between aortic insertion and free margin. In 228 tricuspid AV, prolapse was corrected on 1 (n=130), 2 (n=70), and 3 (n=28) cusps. In 171 bicuspid AV, prolapse was corrected on 1 (n=67) and 2 (n=104) cusps. In 82 cases more than 1 technique was used and the patients were allocated to 1 of 3 groups according to the more extensive repair. CP was performed in 265 (A), TR in 74 (B) and PP was used in 60 patients (C). In tricuspid AV there were significantly more CP and fewer TR (p<0.001). Patients were older in A (58±16 years) compared to B (49±16 years) or C (52±18 years; p<0.001). Concomitant procedures were more frequent in A (aortic root replacement p<0.001; CABG p<0.01). All patients were followed, cumulative follow-up was 1131 patients years (1-131 months, mean 35±27 months).
Results: Hospital mortality was 3.3% (9/269, A), 1.4% (1/74, B) and 0% (C). Actuarial freedom from aortic regurgitation grade =II at 1/ 8 years was 97%/94% (A), 94%/92% (B) and 92/92% (C;p=0.5). Eleven patients were reoperated (A 6; B 3; C 2) with prolapse as most common reason (n=5), 4 were re-repaired. Freedom from reoperation at 1/ 8 years was 99%/95% (A), 97%/ 95% (B) and 97%/97% (C; p=0.7). Freedom from valve replacement at 1/ 8 years was 99% /97% (A), 99%/ 99% (B), and 98%/ 98% (C; p=0.9).
Conclusion: Cusp prolapse is a frequent finding in aortic regurgitation and should be looked for aggressively. Central plication of the free margin, triangular resection with adaptation of remaining tissue, and insertion of pericardial patches can be performed with identically good long-term results. All techniques can be used, provided that adequate cusp configuration can be achieved.
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