AATS: Repair oriented functional classification of aortic insufficiency: impact on surgical techniques and outcomes

AATS: American Association for Thoracic Surgery.

Repair oriented functional classification of aortic insufficiency: impact on surgical techniques and outcomes

Laurent de Kerchove, David Glineur, Alain Poncelet, Jean Rubay, Parla Astarci, Robert Verhelst, Philippe Noirhomme, Gébrine El Khoury; Université Catholique de Louvain, Cliniques St-Luc, Brussels, Belgium

Comment on this Abstract

Objective: In patients with aortic valve insufficiency (AI), valve repair requires a tailored surgery determined by the leaflets and proximal aorta anatomy which prompt us to develop a functional classification of AI. This classification has implication on the surgical strategy and outcome. In this study, we analyze one decade experience with aortic valve (AV) repair.
Methods: From 1996 to 2006, 264 patients underwent elective AV repair for AI. Mean age was 54±16 years (range: 11 to 85) and 79% (209/265) were male. Table 1 describes our functional classification of AI and the corresponding surgical techniques. AV was tricuspid in 171 patients, bicuspid in 90 and quadricuspid in 3. One hundred fifty three patient had type I dysfunction (aortic dilatation), 134 had type II (cusp prolapse), and 40 had type III (restrictive). Thirty one percent (83/264) of the patients had more than one dysfunction.
Results: Hospital mortality is 1.1% (3/264). Six patients experienced early repair failure, of them 3 were re-repaired. Follow-up (mean: 50±34 months, range: 9 to 136) is 94% complete. Late mortality is 4.2% (11/261,10 cardiac). Five years overall survival is 96±3%. During the follow-up period, 4 patients suffered from strokes, 1 from TIA and 1 from AV endocarditis. Late AV reoperation was necessary in 10 patients with one re-repair. Five years freedom from AI >2 and from AV reoperation is respectively 84±7% and 92±4% with no significant difference between tricuspid (80±10%;90±6%) and bicuspid (86±10%;93±5%). Patients with type I (82±9%, 93±5%) or II (95±5%, 94±6%) show better results than patients with type III (76±17%; 84±13%). Moreover, the multivariate analysis showed that 2° pump run and residual AR on discharge are independent risk factors for repair failure.
Conclusion: The functional classification allows a systematic approach of AI and may enhance the reparability rate. Moreover, it facilitates anticipation of the surgical technique and the prediction of the durability. Cusp restrictive motion (type III), due to fibrosis or calcification, is an important limitation for conservative surgery.

Functional Classification of AI		Techniques of repair
Type I	Type 1aDilatation of sino-tubular junction and ascending aorta	Sino-tubular junction remodeling(=supra coronary aortic replacement)+ subcommissural anuloplasty
	Type 1bDilatation of sino-tubular junction and sinuses of Valsalva	Aortic valve sparing:Reimplantation or Remodeling techniques(+ subcommissural anuloplasty in remodeling)
	Type 1cDilatation of aorto-ventricular junction	Subcommissural anuloplasty(+ sino-tubular junction plication)
	Type 1dCusp perforation	Autologous pericardial patch(+ subcommissural anuloplasty)
Type II	Cusp prolapse	Central plication, triangular resection, free margin shortening with PTFE suture, autologous pericardial patch+ subcommissural anuloplasty
Type III	Restrictive cusp motion	Shaving, decalcification, resection and patch repair(+ subcommissural anuloplasty)

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