Aortic valve repair versus pericardial valve replacement

The majority of patients with severe aortic regurgitation (AR) requiring surgery undergo valve replacement. However, some surgical centers have increasing experience in performing aortic valve repair, using a variety of different techniques (Slide 1). Aortic valve (AV) repair by decalcifying stenotic calcific aortic valves was used in the preprosthesis era, but results have been unrewarding and the approach largely discredited. It really took the wide adoption and excellent results of mitral valve repair for mitral regurgitation to prompt interest in repair techniques for aortic insufficiency, not only those involving valve-sparing aortic root reconstruction, but also those relating to the valve cusps. Prolapse can be repaired with triangular resection and re-approximation of cusp tissue (Slide 1A), cusp resuspension, or free-edge cusp plication. For cusp perforation, one option is a simple suture or patch of fresh or glutaraldehyde-fixed autologous pericardium. Rheumatic lesions are clearly more difficult to repair and, in general, these repairs have not been successful over time. However, repair of rheumatic AVs occasionally can be done with incision of the cusp free edge to unroll and thin out the edge possibly combined with cusp extension using autologous pericardium (Slide 1B). Annular dilation can be treated with Dacron strip aortic annuloplasty, circular suture annuloplasty (Slide 1C), commissural plication (Slide 1D), or cusp extension with pericardium (Slide 1B). (For additional information, read Valvular Heart Disease: Surgical Perspectives, by Robert E. Michler, MD, FACC, and Dimitrios C. Angouras, MD, in the American College of Cardiology Self-Assessment Program [ACCSAP] 6.) Among the advantages of AV repair versus replacement: no need for long-term anticoagulation, a low thromboembolic risk, a low endocarditis risk, a hemodynamically efficient valve, and a straightforward reoperation if eventually necessary. The disadvantages are lack of uniform applicability, lack of widespread experience with surgical techniques, and the need for reoperation. A figure is presented. Moreover, all of these approaches remain a surgical challenge and are applicable to only a limited proportion of patients. In general, the 2006 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on managing patients with valvular disease state that AV repair should be considered "only in those surgical centers that have developed the appropriate technical expertise, gained experience in patient selection, and demonstrated outcomes equivalent to those of valve replacement." The indications for valve replacement and repair do not differ. In patients with pure, chronic AR, surgical intervention should be considered only if AR is severe (Slide 2). Patients with only mild AR are not candidates for repair or replacement, and if such patients have symptoms or they have left ventricular dysfunction, then other causes should be considered, such as coronary artery disease, hypertension, or cardiomyopathic processes. If the severity of AR is uncertain after a review of clinical and echocardiographic data, additional information may be needed, such as invasive hemodynamic and angiographic data.