C considerably less attention than the repair of the

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1 Indications and Limitations of Aortic Valve Reconstruction Carlos Duran, MD, PhD, Naresh Kumar, MD, FRCS, Begonia Gometza, MD, and Zohair A1 Halees, MD, FRCS(C) Department of Cardiovascular Diseases, kng Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia To elucidate the value of conservative operation for aortic regurgitation, all consecutive patients operated on between July 1988 and July 1990 were reviewed. Of 251 patients with aortic regurgitation, 107 (42.6%) had nonprosthetic operation. The mean age was 23 years, and 90 patients (84.1%) were rheumatic. Two techniques were used: repair (annular and leaflet plasties, 69 cases) and cusp extension with glutaraldehyde-treated pericardium (25 bovine, 13 autologous). There were two hospital deaths (1.8%), both in the repair group, and no late deaths or embolic events. Only 5 patients (4.7%) were anticoagulated. In the repair group there were 12 reoper- ations, four (5.9%) due to aortic and eight to mitral dysfunction. In the cusp extension group there were two reoperations due to mitral dysfunction. Echocardiographic follow-up showed better results with cusp extension. In conclusion, conservative operation for aortic regurgitation is possible in a high percentage of young rheumatic patients and does not require anticoagulation. Cusp extension is more reliable than repair in terms of early results, although its long-term durability is not yet known. (Ann Thorac Surg ) onservative operation on the aortic valve has received C considerably less attention than the repair of the atrioventricular valves. With the exception of stenotic lesions in the very young and regurgitation secondary to septa1 defects, most surgeons treat all aortic valve lesions with a replacement. This attitude is justified by the satisfactory results of the available prostheses in the aortic area, the lack of valve tissue usually found, and the very precise geometry required to achieve competence. Our long-standing interest in valve repair, together with an encounter with a young population in whom anticoagulation constitutes a major problem, stimulated an aggressive attitude toward aortic valve conservation. To elucidate the value of this approach, all consecutive patients operated on for aortic regurgitation during a 2-year period were reviewed. Analysis of the results should clarify the indications and limits of the different surgical techniques available. years. Forty-seven of these patients (43.9%) were less than 20 years of age. The cause was rheumatic in 84.1%; 81.3% were in New York Heart Association functional class I11 or IV and 87.8% were in sinus rhythm. Seventyseven patients (71.9%) had pure aortic regurgitation and 30 had some degree of stenosis. Of the 107 patients, 42 (39.2%) had an isolated lesion whereas 65 (60.7%) also had a mitral and 22 (20.5%) a tricuspid lesion that also needed operation. Triple-valve operation was performed in 22 patients (20.5%). The diagnosis was established by transthoracic twodimensional color-flow Doppler echocardiography. The degree of aortic regurgitation was graded 1+ to 4+ according to the height of the regurgitant jet relative to the left ventricular outflow tract height, measured from a parasternal long axis just below the aortic valve [l]. The findings were confirmed intraoperatively by a transesophageal probe. Material and Methods Patients Between July 1988 and July 1990, 251 consecutive patients with aortic regurgitation were operated on at our Institution. One hundred forty-four underwent valve replacement and 107 (42.6%), a conservative procedure. This last group constitutes the basis for this report, and their preoperative characteristics are presented in Table 1. Their ages ranged from 4 to 60 years with a mean of 23.0 Presented at the Twenty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Feb 1&20, Address reprint requests to Dr Duran, MBC 16, King Faisal Specialist Hospital, PO Box 3354, Riyadh 11211, Saudi Arabia. Surgical Techniques All patients underwent operation under cardiopulmonary bypass with ascending aorta and single dual-stage right atrial cannulation. Only those with serious tricuspid disease had bicaval cannulation. An apical left ventricular vent and systemic moderate hypothermia (28 C) were used in all patients. After aortic cross-clamping, the aorta was opened transversely close to the clamp. The incision curved downward toward the noncoronary sinus and stopped a few millimeters from the base of the noncoronary cusp. Cold crystalloid cardioplegia injected into the coronary arteries and topical cooling of the heart with ice slush were used routinely in all patients for myocardial protection. An insulating pad was placed behind the by The Society of Thoracic Surgeons /91/$3.50

2 448 DURAN ET AL Ann Thorac Surg Table 1. Preoperative Patient Cha~acteristics" cusp Total Repair Extension Variable (n = 107) (n = 69) (n = 38) p Value Age (Y)b Mean Range Sex Male Female Functional class I I1 I11 1v Cause Rheumatic Congenital Degenerative Pathology Isolated Mitral Mitral + tricuspid ECG Sinus rhythm Atrial fibrillation (59.8) 43 (40.2) 2 (1.8) 18 (16.8) 73 (67.5) 14 (13) 90 (84.1) 15 (14) 2 (1.8) 42 (39) 43 (40.1) 22 (20.5) 94 (87.8) 13 (12.1) Numbers in parentheses are percentages. mode = 17 years. ECG = electrocardiogram; 39 (56.5) 30 (43.5) l(1.4) 11 (15.9) 47 (68.1) 10 (14.4) 54 (78.2) 14 (20.2) l(1.4) 20 (28.9) 30 (43.4) 19 (27.5) 59 (85.5) 10 (14.4) = not significant (65.8) 13 (34.2) l(2.6) 7 (18.4) 26 (68.4) 4 (10.5) 36 (94.7) 1 (2.6) 1 (2.6) 22 (57.8) 13 (34.2) 3 (7.8) 35 (92.2) 3 (7.8) <0.05 <0.05 Median age = 22 years, heart, and the myocardial temperature was monitored continuously by a probe in the septum. The aortic valve was inspected, but if an associated mitral valve lesion was present no decision was made at that time. A left atriotomy was performed and the mitral valve operation undertaken. A successful mitral valve repair was always a reinforcing factor toward aortic conservation. Careful exploration of the aortic valve determined the type of operation. Valves with an active infec- tion, calcification, or bicuspid or unsuitable anatomy were excised and replaced with a prosthesis. If the valve leaflets were relatively thin and only retracted one third or less of their radial length, a repair was attempted. Various surgical maneuvers already described by us [Z, 31 were used either alone or in conjunction to obtain competence, Resuspension of the prolapsed cusp, unrolling of the thickened free edge, subcommissural U annuloplasty stitches, and augmentation of the supraaortic crest were all used (Fig 1). Valves with severe regurgitation due to thickening and gross retraction of more than one half of the leaflet area were candidates for cusp extension, also termed "reconstruction." In these valves, the thickened part of the cusp was resected leaving at least a 5-mm rim of the leaflet tissue. A rectangular strip of glutaraldehyde-treated pericardium was then cut in a tricuspid fashion and sutured to the leaflet remnant with a running 4-0 Prolene (Ethicon, Somerville, NJ) suture started at the midpoint of each leaflet. The new commissures were anchored to the aortic wall by stitches driven through the wall and tied over pledgets on the outside (Fig 2). The quality of repair was assessed during the rewarming period by measuring the amount of vent return after unclamping the aorta. More recently the valve has been directly visualized through a "valvoscope" before unclamping while cardioplegia is injected under pressure. Once the patient was off bypass, transesophageal or epicardial color Doppler echocardiography was performed. All patients had an echocardiographic study performed before discharge and at each follow-up examination. Anticoagulation was dictated by the mitral operation. Patients with isolated aortic operation were not anticoagulated. Those with pericardial reconstruction were given antiaggregants. All patients were followed up at 3-, 6-, and 12-month intervals by one physician. Any patient who failed to report was contacted by a social worker who had visited the patient during his or her hospital stay. All events were recorded according to the set of definitions established by the Ad Hoc Committee on Valvular Surgery [41. Fig 1. Aortic valve repair techniques. Q 6 Commlssurotomy Subcommissural Free Edge cusp Supraaortic Crest Annuloplasty Unrolling Resuspension Enhancement

3 Ann Thorac Surg DURAN ET AL 449 Normal Fig 2. Aortic valve reconstruction with glutaraldehyde-treated pericardium. (A.R. = aortic regurgitation.) -,,-,I\.- Pericardial Graft for.- Cusp Extension Cusp Extension Results In 69 patients, repair was possible, whereas in the remaining 38 reconstruction with glutaraldehyde-treated pericardium was necessary. The first 25 of these latter patients had commercially available bovine pericardium used for their reconstruction, and the last 13 had autologous pericardium. The preoperative patient characteristics of the total group and of the repair and reconstruction groups are shown in Table 1. Although the mean ages were similar, reconstruction was only performed in young patients. More than 80% of the patients had a rheumatic lesion, but 94.7% of those with reconstruction were rheumatic versus 78.2% of those with repair. More isolated aortic lesions were treated by reconstruction (57.8%) than by repair (28.9%). Only 3 patients (7%) with triple-valve operation had reconstruction versus 19 (27.5%) in the repair group. The functional class was similar in both groups of patients (2.8 versus 2.9, reconstruction versus repair). The preoperative echocardiographic degree of aortic regurgitation was significantly different between the two groups (Table 2). The patients with reconstruction had more regurgitation (mean, 3.24 * 0.8) than those with repair (mean, 2.29? 1.1). The surgical repair maneuvers performed in the repair group were 44 commissural annuloplasties, 30 commissurotomies, 18 cusp resuspensions, 16 free edge unrollings, 11 crest enhancements, and 10 other maneuvers. Most patients had more than one maneuver to attain competence (mean, 1.8). Of the 65 patients who had simultaneous mitral operation, 10 (15.4%) had their valve replaced and 55 (84.6%) under- went conservative mitral valve procedures (Table 3). The possibility of mitral repair was an incentive to also conserve the aortic valve. Twenty-one of 22 tricuspid valves were treated conservatively. It is worth noting that none of the patients who underwent aortic reconstruction with pericardium had prosthetic replacement of the other valves; their associated mitral lesion was repaired in 16 and the tricuspid valve was repaired in 3 of them. The mean cardiopulmonary bypass and ischemic time for the whole group was k 46.3 and * minutes, respectively. The mean ischemic time for isolated aortic repair was L 19.6 minutes versus * 21.7 minutes for isolated aortic reconstruction. Reconstruction always took longer than repair. There were two unsuccessful attempts at repair that were followed by cusp extension. However, the unsuccessful attempts at conservation that ended with an aortic replacement are not included in this series. Five patients in the repair group had an unsuccessful attempt at mitral repair followed by replacement. Transvalvular gradients were measured intraoperatively after the patient came off bypass in 16 aortic cusp extensions. The gradients varied between a few millimeters and 20 mm Hg. One single patient, with a mixed aortic lesion, showed a residual gradient of 25 mm Hg. There were two (1.8%) hospital deaths in the whole group; both occurred after repair. One patient had a simultaneous mitral repair, and the other a mitral and tricuspid repair. The cause of death was low cardiac Table 2. Echocardiographic Mean Degree of Aortic Regurgitation (graded 0 to 4+) Group Preoperative Intraopera tive Discharge FO~~OW-UP p Value Repair 2.29? ? ? ? 0.8 c0.05 Cusp extension 3.24? ? ? ? 0.6 <0.05 a Preoperative versus follow-up.

4 450 DURAN ET AL Ann Thorac Surg Table 3. Associated Valve Operations Performed in the 107 Patients With Aortic Conservative Procedures" Total Repair Extension Valve (n = 107) (n = 69) (n = 38) Mitral n 65 (60.7) 49 (71.0) 16 (42.1) Repair 55 (84.6) 39 (79.5) 16 (100) Replacement 10 (15.3) 10 (20.4)... Tricuspid n 22 (20.5) 19 (27.5) 3 (7.8) Repair 21 (95.4) 18 (94.7) 3 (100) Replacement 1 (4.5) l(5.2)... a Numbers in parentheses are percentages. output in one and a spontaneous brain hemorrhage while in the ward in the other. There were no hospital deaths in the reconstruction group. However in 3 patients severe but transient electrocardiographic ischemic changes were detected soon after coming off bypass. These patients, however, did not have permanent residual or recurrent ischemic changes during their hospital stay or in the follow-up period. Ninety-six patients (91.4%) left the hospital in sinus rhythm. The remaining 9 patients (8.6%) were in atrial fibrillation; all had associated mitral disease. Only 5 (4.7%) of the 105 surviving patients with aortic conservation were anticoagulated with warfarin. Fifty-six (53.3%) received antiplatelet drugs and 44 (41.9%) received no treatment. The follow-up of the patients has been complete from a minimum of 6 months to a maximum of 30 months. So far, no thromboembolic events have been detected in this group of patients and there have been no late deaths. Fourteen patients required reoperation (14/105 or 13.3%) due to failure of the aortic or mitral repair. In the repair group, 4 patients had aortic valve dysfunction as the primary cause for reoperation (4167 or 5.9%) and the valve was replaced, whereas in 8 patients dysfunction of the mitral valve repair was the cause of reoperation. In the 8 patients with mitral dysfunction, 4 did not have any procedure done to the repaired aortic valve at the second operation. In the other 4 with only moderate regurgitation, the valve was replaced to reduce the risk of a second reoperation. Three patients were reoperated on within 11 days of the first operation owing to an unsatisfactory surgical technique, whereas the other 9 patients were reoperated on between 2 and 9 months postoperatively. One of these patients was reoperated on at 7 months after rheumatic reactivation. In the pericardial cusp extension group, 2 patients underwent reoperation at 4 and 8 months postoperatively. In both patients reoperation was necessitated by dysfunction of the mitral repair. In 1 of them the aortic valve was reoperated on because of the presence of 2+ regurgitation, present since the first operation. Resuspension of one of the pericardial free edges was performed. In the other patient the aorta was opened just to inspect the appearance of the pericardium. In both patients the bovine pericardium was pliable without evidence of degeneration or calcification. No thrombus formation was observed. There was no mortality in the reoperation group. One patient suffered a transient monoplegia with full recovery. The event-free actuarial curves for the repairs and for the reconstructions are presented in Figure 3. Given that no late deaths or thromboembolic events have yet occurred in this group of patients, these data correspond to freedom from reoperation. The echocardiographic findings preoperatively and intraoperatively, at discharge and at follow-up, are pre- Fig 3. Actuarial freedom from any reoperation on the aortic valve after repair and pericardial cusp extension c cusp extension repair I I I I I I I I

5 Ann Thorac Surg 1991 :52: DURAN ET AL 451 sented in Table 2. Those patients who required reoperation due to aortic dysfunction were not included. At last follow-up, all 38 patients with pericardial reconstruction were in functional class I or I1 with 36 (94.7%) in functional class I. Sixty-three patients (94%) who underwent repair were also in class I or 11. Four patients were in class I11 or IV, all of whom had had multiple-valve operation. Comment Conservative operation on the aortic valve has a long history parallel to the development of cardiac surgery. Before the advent of cardiopulmonary bypass the two techniques described for the treatment of regurgitation were circumclusion [5, 61 and bicuspidization [7, 81. Lillehei and associates [9] in 1958, already using cardiopulmonary bypass, also used bicuspidization and described single-cusp enlargement with an Ivalon sponge. Mulder and colleagues [lo] in 1960 described a variety of surgical maneuvers that they referred to as valvuloplasty. The advent of the valve prostheses, with their ease of implantation and guaranteed immediate competence, soon displaced the rather unpredictable conservative maneuvers. More recently, the awareness of the long-term problems of the available prostheses and the standardization and universal acceptance of the repair techniques on the atrioventricular valves have awakened a new interest in aortic valve repair. Our encounter with a mostly rheumatic, young population in whom anticoagulation represents a very serious problem in terms of compliance and frequent pregnancies stimulated an aggressive attitude toward valve conservation. The fact that 60% of our patients undergoing aortic operations required concomitant mitral operation, in which the mitral valve was very often successfully repaired, further stimulated avoidance of an aortic prosthesis. The mean age (23 years) and etiology (84% rheumatic) reflect both the type of population and our indications for aortic conservation. It was considered that beyond 35 years of age the durability of a bioprosthesis is reasonable and justifies its use when anticoagulation contraindicates the implantation of a mechanical prosthesis. The conservative surgical techniques applied fell under two distinct categories. Those patients judged to have enough valvular tissue underwent a variety of techniques directed toward achieving competence without the use of any extravalvular tissue [2]. These techniques, grouped under the heading of repair, should be taken as a whole, as usually each of them only achieves partial improvement and requires reinforcement by others. A review of the long-term results obtained in a group of 50 patients who underwent operation with these techniques between 1974 and 1986 showed a 13-year actuarial survival of 86% and only four reoperations due to severe aortic dysfunction [3]. These techniques included (1) commissurotomy, always performed in the presence of even minimal fusion to maximize cusp mobility; (2) unrolling of the free edge of each leaflet, which increases the area by a few millimeters; (3) annuloplasty by means of the placement of a pledgeted U stitch at the base of each commissure, which by plicating the aortic wall reduces its total circumference (this technique, which we described as original [2], had in fact already been described by Cabrol and associates in 1966 [ll, 121; very recently, Cosgrove and co-workers [13] reported its successful use in a group of 21 patients); (4) in those cases with prolapse, the resuspension of the cusp free edge was also performed following the technique of Trusler and colleagues [14]; and (5) finally, in some cases an enhancement of the supraaortic ridge was induced to improve the valve hemodynamics. We [ 151 recently showed in the experimental animal that this technique induces an earlier closure of the aortic valve probably due to an increase in the vortices within the sinuses of Valsalva. It can be postulated that this vortex increase would reduce the tendency toward the inward rolling of the leaflet free edges. In any case, this is a very fast surgical maneuver that, at worst, is innocuous. Among the 65 survivors in whom we used these techniques, 12 required reoperation but dysfunction of the concomitant mitral repair was the cause in 8 of them. Eight aortic valves (12.3%) were, however, replaced due to severe regurgitation in 4 and moderate regurgitation in the other four. It was believed that the risk of a second reoperation should be reduced in this very young group of patients in whom rheumatic reactivation is a permanent threat. In the presence of very severe cusp retraction, these maneuvers cannot be used and extension of all three cusps was performed with a single strip of glutaraldehyde-treated pericardium. These patients were grouped as reconstruction. Two main questions must be addressed when considering the use of this approach. The first is the need for a standard surgical technique that ensures a correct, reproducible, and safe result in terms of immediate competence. The second is the long-term durability of the selected material. The data from our series show that this surgical technique achieves immediate competence in all cases as shown by intraoperative echocardiography. However, in 3 patients intermittent electrocardiographic ischemic changes were observed after bypass. It is interesting to note that Batista and associates [16] reported that the only four operative deaths in their series were due to severe myocardial dysfunction in 3 patients and a myocardial infarction in the fourth without any obvious coronary problem at autopsy. Since we started using the valvoscope before aortic unclamping, in 3 patients the left coronary part of the pericardium was observed as prolapsing outwardly toward the sinus of Valsalva. The aortotomy was reopened and a few millimeters of the pericardial free edge were resected. It can be postulated that too long a piece of pericardium can prolapse and induce left coronary ischemia. The second important question is the durability of the glutaraldehyde-treated pericardium. During the 1960s a variety of techniques were used for single or multiple cusp extension, but with rather poor results. In 1964 Bjork and Hultquist [ 171 reported the calcification of single-cusp autologous pericardium used in 2 patients. In 1967 Bailey [18] and Kay [19] described the use of aortic wall and homologous and heterologous cusps, respectively.

6 452 DURAN ET AL Ann Thorac Surg 1991:52: Bahnson and associates [20] in 1969 studied the use of pericardium, peritoneum, pleura, and fascia lata to construct single aortic cusps. In the same year Edwards [21] described a technique for the use of a single pericardial strip. The small number of cases and lack of adequate myocardial protection probably resulted in poor anatomical results, which invalidates any conclusion. The much larger negative experience of fresh autologous fascia lata described by Senning [22] emphasizes the importance of tissue pretreatment. More recently, several authors have used glutaraldehyde-treated bovine pericardium with, so far, favorable results. Batista and co-workers [16] in 1986 described a technique for the enlargement of all three cusps with a single strip of pericardium. Batista later reported that no calcification had occurred in 206 patients with a maximum follow-up of 6 years [23]. Yacoub and associates (24, 251 reported 6 cases of early tears (mean, 3.3 months) and four degenerations among 135 patients followed up for a maximum of 7 years in whom glutaraldehyde-treated strips of calf pericardium had been used. In 1988 A1 Fagih and co-workers [26] reported the use of bovine pericardium for single-cusp extension in 20 cases with a maximum follow-up of 23 months. On the other hand the rather limited durability of the Ionescu-Shiley bioprosthesis [27], particularly in the young patient [28], cast some doubt on the long-term results of glutaraldehyde-treated bovine pericardium. The absence of a rigid stent when used in cusp extension, however, not only reduces the transvalvular gradient, especially important in very young patients, but also reduces the tissue stress, hopefully increasing its durability. This hypothesis is supported by the reports of Angel1 and colleagues [29, 301 showing that the time to free-hand homograft failure is approximately 12 years versus 8 years when the homograft is mounted on a stent. Even in the event of failure, the excision of the calcified pericardium should be easy, given that the patient s leaflet remnants have been preserved. The recent report by Chachques and associates [31] of the biological advantages of glutaraldehyde-treated autologous pericardium and its clinical application for cusp extension in the mitral position [32] encouraged us to use it in the last 13 patients. In this series, 2 patients with cusp extension were reoperated on because of dysfunction of the mitral valve at 4 and 8 months postoperatively. In 1 of them, the aorta was opened just to observe the aortic reconstruction. The pericardium was thin and pliable, and no operation was undertaken. In the other patient, who had 2+ aortic regurgitation present since the first operation, the pericardium was also thin and mobile, but one of the cusps was too long and therefore a plication of its free edge was performed. The total hospital mortality of 2 patients (1.8%) reflects the young age of our population. Both patients were in the repair group, and 1 of them died due to a cerebral hemorrhage just before discharge. During the short (although complete) follow-up available, no thromboembolic events or late deaths have occurred. It is worth noticing that only 5 patients in the whole series, who were in atrial fibrillation and had a mitral bioprosthesis, were anticoagulated. The follow-up of this group of patients is still too short to derive a meaningful long-term outcome. However, the object of this report is to show that for a certain group of patients in whom anticoagulation represents a serious problem, conservative operation on the aortic valve can be performed in a high percentage of cases. This is particularly relevant for those patients who have had a successful mitral valve repair, in whom a nonprosthetic option for the aortic valve regurgitation would be preferable. The absolute best type of patients for the repair techniques described are patients with successful mitral repair and moderate aortic regurgitation too serious to be ignored. When the regurgitation is severe these maneuvers are unlikely to achieve perfect competence and cusp extension is necessary. In these cases only the age of the patient and difficulty of anticoagulation justify the use of autologous pericardium until its long-term behavior is better known. Aortic valve conservation, even though free of valve-related morbidity and mortality, carries a risk of reoperation practically always of a technical nature. This incidence should be reduced with a greater reliance on intraoperative echocardiography and a better knowledge of the limits of this operation. This work was supported in part by external grant AT from the King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia. We thank Dr F. Khouqeer for making available the charts of his patients, Dr E. Mercer for the echocardiographic studies, Miss Layla A1 Ashgar, social worker, for her cheerful persistence in tracking all patients, and Miss Alison Silkstone for her enthusiastic and dedicated secretarial assistance. References 1. Perry GJ, Helmoke F, Nanda NC, Byard C, Soto B. Evaluation of aortic insufficiency by Doppler color flow mapping. J Am Coll Cardiol 1987;9: Duran CMG. Reconstructive techniques for rheumatic aortic valve disease. J Cardiac Surg 1988;3: Duran CMG, Alonso J, Gaite L, et al. Long term results of conservative repair of the rheumatic aortic valve insufficiency. Eur J Cardiothorac Surg 1988;2: Edmunds LH, Clark RE, Cohn LH, Miller DC, Weisel DR. Guidelines for reporting morbidity and mortality after cardiac valvular operations. Ann Thorac Surg 1988;46: Taylor WJ, Thrower WB, Black H, Harken DE. The surgical correction of aortic insufficiency by circumclusion. J Thorac Cardiovasc Surg 1958;35: Murphy JP. The surgical correction of syphilitic aortic insufficiency. J Thorac Cardiovasc Surg 1960;40: Starzl TE, Cruzat EP, Walker FB, Lewis FJ. A technique for bicuspidization of the aortic valve. J Thorac Cardiovasc Surg 1959;38: Hurwitt ES, Hoffert PW, Rosenblatt A. Plication of the aortic ring in the correction of aortic insufficiency. J Thorac Cardiovasc Surg 1960;39: Lillehei CW, Gott VL, DeWall RA, Varco RL. The surgical treatment of stenotic or regurgitant lesions of the mitral and aortic valves by direct vision utilizing a pump oxygenator. J Thorac Cardiovasc Surg 1958;35:

7 Ann Thorac Surg DURAN ET AL Mulder DG, Kattus AA, Longmire WP. The treatment of acquired aortic stenosis by valvuloplasty. J Thorac Cardiovasc Surg 1960;40: Cabrol C et A, Guiraudon G, Bertrand M. Le traitement de I'insuffisance aortique par I'annuloplastie aortique. Arch Ma1 Coeur 1966;59: Rocache M, Cabrol C et A, Guiraudon G, et al. Resultats eloignes des annuloplasties aortiques. Arch Ma1 Coeur 1971; 65: Cosgrove DM, Rosenkranz ER, Steward WJ, Hendren WG. Valvuloplasty for aortic insufficiency. Presented at the 70th Annual Meeting of the American Association for Thoracic Surgery, Toronto, Ont, Canada, May 7-9, Trusler GA, Moes CAF, Kidd BSL. Repair of ventricular septa1 defect with aortic insufficiency. J Thorac Cardiovasc Surg 1973;66: Duran CMG, Balasundaram S, Bianchi S, Ahmad R, Wilson N. Hernodynamic effect of supraaortic ridge enhancement on the closure mechanism of the aortic valve and its implication in aortic valve repair. Thorac Cardiovasc Surg 1990;38:& Batista RJV, Dobrianskij A, Comazzi M, et al. Clinical experience with stentless pericardial monopatch for aortic valve replacement. J Thorac Cardiovasc Surg 1987;93: Bjork VO, Hultquist G. Teflon and pericardial aortic valve prostheses. J Thorac Cardiovasc Surg 1964;47: Bailey ChP. Discussion of: Senning A. Fascia lata replacement of aortic valves. J Thorac Cardiovasc Surg 1967;54: Kay EB. Discussion of: Senning A. Fascia lata replacement of aortic valves. J Thorac Cardiovasc Surg 1967;54: Bahnson HT, Hardesty RL, Baker LD Jr, Brooks D 11, Gall DA. Fabrication and evaluation of tissue leaflets for aortic and mitral valve replacement. Ann Surg 1970;171: Edwards WS. Aortic valve replacement with autogenous tissue. Ann Thorac Surg 1969;8:12& Senning A. Fascia lata replacement of aortic valves. J Thorac Cardiovasc Surg 1967;54: Batista RJV. Discussion of: David TE, Pollick C, Bos J. Aortic valve replacement with stentless porcine aortic bioprosthesis. J Thorac Cardiovasc Surg 1990;99: Yacoub M, Khaghani A, Dhalla N, et al. Aortic valve replacement using unstented dura or calf pericardium: early and medium term results. In: Bodnar E, Yacoub M, eds. Biologic and bioprosthetic valves. New York: Yorke Medical Books, 1986: Khaghani A, Mankand P, Dhalla N et al. Aortic valve replacement using unstented dura or calf pericardium: early and medium term results [Abstract]. J Am Coll Cardiol 1987;9:8A. 26. A1 Fagih MR, A1 Kasab SM, Ashmeg A. Aortic valve repair using bovine pericardium for cusp extension. J Thorac Cardiovasc Surg 1988;96: Duran CMG. The pericardial heart valve. An open question. In: DAlessandro LC, ed. Heart surgery Roma: Casa Editrize Scientifica Internazionale, 1989: Ode11 JA, Gillmer D, Whitton ID, Vythilingum SP, Vanker EA. Calcification of tissue valves in children: occurrence in porcine and pericardial bioprosthetic valves. In: Bodnar E, Yacoub M, eds. Biological and bioprosthetic valves. New York: Yorke Medical Books, 1986: Angell WW, Angell JD, Oury JH, Lamberti JJ, Grehl TM. Long term follow-up of viable frozen aortic homografts: a viable homograft bank. J Thorac Cardiovasc Surg 1987;93: Angell WW, Oury JH, Lamberti JJ, Koziol J. Durability of the viable aortic allograft. J Thorac Cardiovasc Surg 1989;98: Chachques JC, Vasseur B, Perrier P, Balansa J, Chauvaud S, Carpentier A. A rapid method to stabilize biological materials for cardiovascular surgery. Ann N Y Acad Sci 1988;529: Chauvaud SM, Chachques JM, Mihaileanu S, Arnaud-Crozat E, Leca F, Carpentier A. Valvular extension with autologous pericardium preserved with glutaraldehyde. Results in mitral valve repair. Presented at the 70th Annual Meeting of the American Association for Thoracic Surgery, Toronto, Ont, Canada, May 7-9, DISCUSSION DR DELOS M. COSGROVE I11 (Cleveland, OH): This report is another seminal contribution by Dr Duran to our knowledge and capability to repair insufficient aortic valves. For 20 years he has led the way in exploring new techniques and reporting his results. We have followed this work closely and borrowed heavily from it. The increasing ability to repair aortic valves is apparent in this series, where 43% of insufficient valves were reconstructed. At the Cleveland Clinic the incidence has increased to 21% in the period 1988 through However, aortic valve repair lags substantially behind repair of atrioventricular valves. There are three reasons for this. First, the mechanism of insufficiency has not been well understood; further, there has been no reliable intraoperative method for valve function analysis; and third, there is less healthy tissue in the aortic position with which to reconstruct the valve. Substantial progress has been made in each of these areas. Carpentier has classified the causes of insufficiency according to the range of motion of the leaflets. This has provided an intellectual framework upon which we can build our understanding of the mechanism of insufficiency. Cusp extension, as reported here, corrects the restricted leaflet motion. Intraoperative echocardiography has been an advance in our ability to visualize the aortic cusp function in the physiological state. It has become an integral part of valve reconstruction, providing the quality control essential for consistent results. A valvoscope, as described in the report, would be a further advance, allowing direct visualization. The third major impediment to aortic reconstruction, lack of sufficient healthy tissue, has in large part been solved by the technique of cusp extension. We have used this technique in single cusp reconstruction and found our results to be inconsistent. Assuming that pericardium is a stable valve substitute as reported by Chauvaud at the meeting of American Association for Thoracic Surgery, standardization of this technique is the remaining hurdle to widespread application. Dr Duran, could you share with us your current thinking on the technique of cusp extension and the status of your valvoscope? DR DURAN: Thank you very much, Dr Cosgrove, for your kind and very pertinent comments. You pinpoint the three main problems that face aortic valve repair. The first one, as in mitral repair, is identifying the exact lesions responsible for the regurgitation to apply the appropriate solution. We have advanced considerably in this field. The second one is the need for a reliable intraoperative method for testing valve competence. We now use

8 454 DURAN ET AL Ann Thorac Surg a modified cystoscope that is introduced through the partially The third Point is the surgical technique of Pericardial CUSP closed aortotomy; while the aorta remains clamped, cardioplegia extension. Our initial experience with individual cusp extension is run under pressure so we can observe the closed repaired was rather poor, and we therefore moved toward a sing1e aortic valve, We found this method very useful, allowing us to pericardial three-cusp extension as described by Batista. We, however, modified it substantially based on the echocardioreopen the aortotomy and apply further reconstructive maneugraphic aortic annulus diameter. The autologous pericardial strip vers such as further trimming of the pericardial free edge after is molded into three curved cusps of the appropriate size by cusp extension. Once the patient is off bypass, intraoperative immersion in glutaraldehyde for 10 minutes, This strip is cut echocardiography, either transesophageal or epicardial, is essen- down according to the amount of patient s tissue left, This tial. We found epicardial echocardiography particularly useful in technique is simple and has been shown to achieve immediate aortic repair. competence.