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Mechanisms of Recurrent Aortic Regurgitation After Aortic Valve Repair

Predictive Value of Intraoperative Transesophageal Echocardiography

Jean-Benoît le Polain de Waroux, MD^_*, Anne-Catherine Pouleur, MD^_*, Annie Robert, PhD, Agnès Pasquet, MD, PhD^_*, Bernhard L. Gerber, MD, PhD^_*, Philippe Noirhomme, MD, Gébrine El Khoury, MD, Jean-Louis J. Vanoverschelde, MD, PhD^_*,_*

^_* Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
Division of Cardiovascular Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
Division of Epidemiology and Biostatistics, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium

^_* Reprint requests and correspondence: Dr. Jean-Louis J. Vanoverschelde, Division of Cardiology, Cliniques Universitaires St-Luc, Avenue Hippocrate, 10-2881, B-1200 Brussels, Belgium (Email: vanoverschelde{at}card.ucl.ac.be).

Objectives: The aim of the present study was to examine the intraoperative echocardiographic features associated with recurrent severe aortic regurgitation (AR) after an aortic valve repair surgery.

Background: Surgical valve repair for AR has significant advantages over valve replacement, but little is known about the predictors and mechanisms of its failure.

Methods: We blindly reviewed all clinical, pre-operative, intraoperative, and follow-up transesophageal echocardiographic data of 186 consecutive patients who underwent valve repair for AR during a 10-year period and in whom intraoperative and follow-up echo data were available. After a median follow-up duration of 18 months, 41 patients had recurrent 3+ AR, 23 patients presented with residual 1+ to 2+ AR, and 122 had no or trivial AR. In patients with recurrent 3+ AR, the cause of recurrent AR was the rupture of a pericardial patch in 3 patients, a residual cusp prolapse in 26 patients, a restrictive cusp motion in 9 patients, an aortic dissection in 2 patients, and an infective endocarditis in 1 patient.

Results: Pre-operatively, all 3 groups were similar for aortic root dimensions and prevalence of bicuspid valve (overall 37%). Patients with recurrent AR were more likely to display Marfan syndrome or type 3 dysfunction pre-operatively. At the opposite end, patients with continent AR repair at follow-up were more likely to have type 2 dysfunction pre-operatively. After cardiopulmonary bypass, a shorter coaptation length, the degree of cusp billowing, a lower level of coaptation (relative to the annulus), a larger diameter of the aortic annulus and the sino-tubular junction, the presence of a residual AR, and the width of its vena contracta were associated with the presence of AR at follow-up. Multivariate Cox analysis identified a shorter coaptation length (odds ratio [OR]: 0.8, p = 0.05), a coaptation occurring below the level of the aortic annulus (OR: 7.9, p < 0.01), a larger aortic annulus (OR: 1.2, p = 0.01), and residual aortic regurgitation (OR: 5.3, p = 0.01) as risk factors of repair failure.

Conclusions: Our results demonstrate that intraoperative transesophageal echocardiography can be used to identify patients undergoing AR repair who are at increased risk for late repair failure.

Key Words: aortic valve repair • transesophageal echocardiography • aortic regurgitation • aortic valve surgery • aortic prolapse

Abbreviations and Acronyms   AR = aortic regurgitation   LV = left ventricular   TEE = transesophageal echocardiography