What question did this study set out to answer?

To present standardized techniques for autologous surgical repair of isolated right coronary leaflet prolapse in patients with aortic insufficiency.

March 3, 2022JTCVS TechniquesOpen Access

Aortic valve repair for isolated right coronary leaflet prolapse

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Why the study?

Isolated right coronary leaflet prolapse is a common cause of nonaneurysmal aortic insufficiency, prompting the presentation of standardized techniques for routine autologous repair.

Does a standardized repair technique using geometric ring annuloplasty, leaflet plication, and ultrasonic nodular release improve repair outcomes in patients with isolated right coronary leaflet prolapse?

Key Points

To present standardized techniques for autologous surgical repair of isolated right coronary leaflet prolapse in patients with aortic insufficiency.
Evaluated diagnostic signs including posteriorly eccentric aortic insufficiency jets and right leaflet tip fractures on echocardiography.
Applied a reconstructive approach combining internal geometric ring annuloplasty, central leaflet plication, and ultrasonic nodular release targeting leaflet coaptation heights of at least 8 mm.
Illustrated techniques using video recordings across six clinical cases with isolated leaflet prolapse and related aortic pathologies.
Surgical reconstruction successfully achieved target equivalent coaptation heights of at least 8 mm across all three leaflets.
Technique yielded excellent early and late repair outcomes without requiring prosthetic valve replacement.

Structured PICO

Population

6 patients with isolated right coronary leaflet prolapse and alternative pathologies

Intervention

Aortic valve repair using internal geometric ring annuloplasty, central leaflet plication, and ultrasonic nodular release

Outcome

Repair outcomes (achieving equivalent coaptation heights of ≥8 mm for all 3 leaflets)

A standardized surgical approach combining geometric ring annuloplasty, leaflet plication, and ultrasonic nodular release enables effective repair of isolated right coronary leaflet prolapse.

Implication

Autologous repair techniques may be feasible in select aneurysm patients; leaves open need for prospective validation before wider adoption.

Abstract

Objectives: Isolated right coronary leaflet prolapse is a common cause of nonaneurysmal aortic insufficiency, but can rarely occur in patients with proximal aortic aneurysms. Standardized techniques for routine autologous repair of this disorder are presented. Methods: Most aortic valve leaflet prolapse is isolated to the right coronary leaflet, with hypertension and annular dilatation being contributory. Echocardiographically, a posteriorly eccentric aortic insufficiency jet together with "fracture" of the right leaflet tip are diagnostic. Primary repair includes internal geometric ring annuloplasty to downsize and reshape the annulus, together with central plication of the prolapsing leaflet. Thickened, scarred, or retracted noduli are released using an ultrasonic aspirator. The goal is to achieve equivalent coaptation heights of ≥8 mm for all 3 leaflets. Results: Three videos of 6 cases are provided to illustrate these techniques. In the first, 3 patients are shown with classic isolated right leaflet prolapse. In the second and third videos, alternative pathologies are presented for contrast. Applying the reconstructive approaches of geometric ring annuloplasty, leaflet plication, and ultrasonic nodular release, excellent early and late repair outcomes are obtainable in most patients. Conclusions: The combination of aortic ring annuloplasty, central leaflet plication, and ultrasonic nodular release allows routine and standardized repair of right coronary leaflet prolapse, either isolated or concomitant with aneurysm surgery.