Mechanisms of Recurrent Aortic Regurgitation After Aortic Valve RepairPredictive 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
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Figure 1 Schematic Representation of the TEE Measurements
Measurements were performed pre-operatively and immediately after bypass. (a) Aortic annulus; (b) sinuses of Valsalva; (c) sino-tubular junction; (d) ascending aorta; (e) height of the sinus of Valsalva; (f) distance from coaptation tips to aortic wall (the symmetry of coaptation within the sinuses of Valsalva was estimated by the absolute difference of the distance separating the tip of the coaptation from the anterior and the posterior border of the sinus of Valsalva); (g) distance from the aortic annulus to the belly of the lowest cusp (degree of cusp billowing if present); (h) distance from the tip of the cusp coaptation to the aortic annulus (relative level of cusp coaptation); and (i) the coaptation length.  = angle between regurgitant AR jet and left ventricular outflow tract. AR = aortic regurgitation; TEE = transesophageal echocardiography.
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Figure 2 Flow Chart of the Study Protocol
During the study period, aortic valve repair was performed in 244 patients; 56 patients lacking TEE data or follow-up were excluded from the present study. In addition, 2 patients were excluded because their aortic valve was reoperated on in the absence of severe recurrent AR (one had an aorto-right ventricular communication, and the other had a pure calcified aortic stenosis). Ultimately, 122 patients with no or trivial AR, 23 patients with 1+ to 2+ AR, and 41 patients with  3+ AR were included. Abbreviations as in Figure 1.
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Figure 3 Case Failure Examples
Representative examples of immediate post-repair intraoperative and late post-repair TEE in 3 patients with 3+ recurrent AR. The post-repair intraoperative TEE illustrates poor, low coaptation level, and eccentric residual AR jets in all 3 patients. In all 3 cases, the follow-up echocardiography as well as the surgical inspection identified cusp prolapse as the cause of AR recurrence. Abbreviations as in Figure 1.
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Figure 4 Risk of Repair Failure According to TEE
This chart represents the hierarchical risk of aortic valve repair failure according to 3 powerful predictors identified with the multivariate analysis. When the level of coaptation of the aortic valve relative to the aortic annulus is successfully evaluated, the presence or absence of residual AR and the length of coaptation enables one to identify patients at risk for repair failure. Abbreviations as in Figure 1.
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Figure 5 4-Year Survival Free From Redo According to TEE
Kaplan-Meier estimates of 4-year survival free from recurrence of 3+ AR in patients whose coaptation was below the level of the aortic annulus (group 1), in those whose coaptation was above the aortic annulus and either had no residual AR (group 2) or displayed residual AR with (group 3) or without (group 4) a coaptation length <4 mm. Abbreviations as in Figure 1.
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