Correction of leaflet prolapse extends the spectrum of patients suitable for valve-sparing aortic root replacement

Abstract

Objective: Preservation of the native aortic valve in patients requiring aortic root replacement avoids the need for lifelong anticoagulation and potentially offers greater durability than a bio-prosthetic valve. Such techniques have generally been applied to patients with early grades of aortic regurgitation (AR) and less severe aortic root dilatation where leaflets have been minimally stretched. We reviewed our experience with these techniques and in particular the durability of the addition of leaflet prolapse correction in patients with more advanced aortic root pathology compared to those with non-prolapsing leaflets. Methods: A total of 61 patients with tri-leaflet valves underwent valve-sparing aortic root replacement, of which 42 (69%) had leaflet prolapse correction. There were 48 (79%) males and mean age was 61 ± 13 years. The majority of patients had either severe AR secondary to aortic root dilatation or aortic root aneurysms. Grade 3+ or 4+ AR was present in 47 (77%) patients. The re-implantation technique was performed in 53 (87%) patients and the remodelling in eight (13%) patients. Concomitant cardiac procedures were performed in 29 (48%) patients including aortic arch reconstruction in 15 (25%). Results: There were three (4.9%) in-hospital and one late death. Mean follow-up was 28 ± 26 months and was 98% complete. Five patients developed grade 3 or 4 AR, of whom three required aortic valve replacement (AVR), which was performed uneventfully. Five-year survival was 95 ± 2.8%. Freedom from AR was 88 ± 5.3% and freedom from AVR was 93 ± 4.1% at 5 years. Patients who had correction of leaflet prolapse experienced equivalent freedom from significant AR to those who did not require it. Conclusion: Patients with large aortic root aneurysms and advanced AR often have stretched leaflets that will prolapse and lead to early failure if only root geometry is corrected. With the addition of leaflet prolapse correction, we have shown equivalent durability to those without stretched leaflets. This has allowed valve preservation in a sizable subgroup who would otherwise have received prosthetic valves. Greater patient numbers and longer follow-up are needed to fully validate this approach.