A Review of Surgical Aortic Valve Repair. Indications and techniques for the General Cardiologist

Q: What is the clinical evidence from this study?

Study design: Review. Population: Surgical aortic valve disease (aortic insufficiency, aortic root aneurysm, tricuspid, bicuspid, and unicuspid aortic valves). Intervention: Surgical aortic valve repair (including valve-sparing root replacement and leaflet repair techniques) vs. Surgical aortic valve replacement (AVR) with mechanical or biologic prosthesis.

Jeremy Docekal

doi:10.31579/2641-0419/073

July 10, 2020Clinical Cardiology and Cardiovascular InterventionsOpen Access

A Review of Surgical Aortic Valve Repair. Indications and techniques for the General Cardiologist

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Key result

Surgical aortic valve repair offers consistent, durable outcomes with low operative mortality (0.8%-3.4%) and 80%-93% 10-year freedom from reoperation in selected patients at high-volume centers.

Why the study?

Does surgical aortic valve repair improve long-term survival and reduce valve-related complications compared to prosthetic aortic valve replacement in young patients with aortic insufficiency or aortic root pathology?

Key Points

To review the clinical indications, basic operative techniques, echocardiographic surgical planning, and long-term outcomes of surgical aortic valve repair.
Narrative review synthesizing clinical indications, operative strategies, and echocardiography-guided planning for aortic valve repair.
Evaluated published outcome data across single-center cohorts examining surgical durability, mortality, and reoperation rates.
A cohort of 640 valve repairs demonstrated an overall hospital mortality rate of 3.4% (0.8% for isolated repair), with 10-year freedom from reoperation of 81% for bicuspid and 93% for tricuspid valves (p = 0.0013).
In 852 repaired bicuspid aortic valves, reoperation rates were 12.3% at 10 years and 21.7% at 15 years, with higher reoperation risk associated with calcification (HR, 4.34; 95% CI, 1.69-11.16; P = .002) and pericardial patch use (HR, 4.00; 95% CI, 1.65-9.66; P = .002).

Structured PICO

Does surgical aortic valve repair improve long-term survival and reduce valve-related complications compared to prosthetic aortic valve replacement in young patients with aortic insufficiency or aortic root pathology?

P

Population

Selected patients with surgical aortic valve disease (aortic insufficiency or aortic root aneurysm), particularly young patients and those in high-risk occupations such as the military.

I

Intervention

Surgical aortic valve repair (AV repair), including valve-sparing aortic root replacement (remodeling and David reimplantation techniques), effective height caliper assessment, leaflet repair (central plication, Gore-Tex free-margin resuspension, triangular resection, pericardial patch reconstruction, sinus plication), and unicuspid valve bicuspidization.

C

Comparator

Surgical aortic valve replacement (AVR) with mechanical or biologic prosthesis (or Bentall procedure / Ross procedure discussed as alternatives).

Limitations

Currently, there are no head-to-head randomized trials comparing surgical aortic valve repair to valve replacement.
Surgical aortic valve repair remains an underutilized technique in the United States, with only 5% of STS database institutions performing >16 aortic valve-sparing procedures in 2009.
Use of pericardial patch for leaflet reconstruction, especially in bicuspid aortic valves, and preoperative commissural orientation <160 degrees are associated with reduced repair durability.
Absence of head-to-head trials comparing surgical aortic valve repair directly to valve replacement
Slow adoption and low procedural volume at most US centers (only 5% of STS ACSD centers performed >16 valve-sparing procedures in 2009)
Adjunctive surgical techniques are required intraoperatively in roughly 35% of patients that were not anticipated on preoperative echocardiographic evaluation
Reduced durability when pericardial patch reconstruction is used (especially in bicuspid aortic valves) or in the presence of significant leaflet calcification

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Implication

Surgical aortic valve repair aided by pre-procedural echocardiographic functional classification and intraoperative effective height measurement provides a durable, anticoagulation-free alternative to prosthetic valve replacement for selected young patients with aortic regurgitation or root aneurysm.

Abstract

The management of surgical aortic valve disease is particularly challenging among young patients and patient's employed in high risk occupations such as the military.Longer life expectancy predicts an increased probability for prosthetic-valve-related complications.Consequently, there is a recognized need for alternative therapies, and surgical aortic valve repair may offer an attractive option for selected patients.Furthermore, aortic valve repair surgical techniques have evolved, and data from contemporary studies show consistent, successful, and durable outcomes; particularly when performed in high volume centers.The purpose of this review is to discuss the indications for aortic valve repair, review basic operative techniques, and illustrate how pre-procedural echocardiographic imaging is contributing to surgical planning.

Discussion

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Cite This Study

Jeremy Docekal (2020) conducted a review in Surgical aortic valve disease (aortic insufficiency, aortic root aneurysm, tricuspid, bicuspid, and unicuspid aortic valves). Surgical aortic valve repair (including valve-sparing root replacement and leaflet repair techniques) vs. Surgical aortic valve replacement (AVR) with mechanical or biologic prosthesis was evaluated. Surgical aortic valve repair offers consistent, durable outcomes with low operative mortality (0.8%-3.4%) and 80%-93% 10-year freedom from reoperation in selected patients at high-volume centers.

synapsesocial.com/papers/6a736ae220644e164b4e5973 https://doi.org/10.31579/2641-0419/073

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A Review of Surgical Aortic Valve Repair. Indications and techniques for the General Cardiologist

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

A Review of Surgical Aortic Valve Repair. Indications and techniques for the General Cardiologist

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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