Abstract 3179: Intraoperative Transoesophageal Echocardiographic Predictors of Recurrent Aortic Regurgitation after Aortic Valve Repair.
Background. Surgical valve repair for aortic regurgitation (AR) has significant advantages over valve replacement, but little is known about the mechanisms of its failure. This echocardiographic study examines the intraoperative features associated with “late failure” of valve repair, eventually necessitating reoperation.
Method. Intraoperative transesophageal echocardiography (TEE) after cardiopulmonary bypass was performed in 168 consecutive patients (pts) undergoing valve repair for AR over a 10-year period. From this cohort, we carefully reviewed all clinical, pre-operative, intraoperative and follow-up TEE data of 62 pts (group A, 53 ± 13 years) with no or trivial AR at follow-up and 31 pts (group B, 46 ± 15 years) with recurrent severe AR at follow-up of whom 17 needed a re-operation. In these pts, echocardiography identified the cause of repair failure as rupture of a pericardial patch in 2 pts, residual cusp prolapse in 18 pts, restrictive cusp motion in 8 pts, aortic dissection in 2 pts and endocarditis in the remaining pt.
Results. Pre-operatively, both groups were similar for aortic root dimensions and incidence of bicuspid valve (39 ± 4 % vs 35 ± 5 %, χ2 = 0.4). Marfan disease and restrictive cusp motion or endocarditis were more frequent in group B than in group A (16 ± 4% vs 0% and 48 ± 5% vs 14 ± 3%, χ2 = 0.001). After cardiopulmonary bypass, the coaptation length was shorter (2.2 ± 1.5 vs. 6.8 ± 2.8 mm, p<0.001), the level of coaptation (relative to the annulus) was lower (0.0 ± 4.4 vs 6.9 ± 3.9 mm, p<0.001), the aortic annulus was larger (27 ± 5 vs 22 ± 4 mm, p<0.001) and the vena contracta was wider (2.4 ± 1.0 vs 0.05 ± 0.9 mm, p<0.001) in group B than in group A pts. Interestingly, 13/18 (72%) pts in whom recurrent AR was due to a cusp prolapse, had eccentric AR jets before leaving the operating room. With multivariate analysis, only a coaptation length < 5 mm (OR=13.1, 95%CI [2.4; 70.5] p=0.003), the presence of an eccentric jet (OR=8.02, 95%CI [2.1; 30.4] p=0.002) and the level of coaptation relative to the aortic annulus (OR=4.7, 95%CI [1.0; 21.6] p=0.049) were found to independently predict late AR recurrence.
Conclusion. Our results demonstrate that intraoperative TEE can be used to identify pts undergoing AR repair who are at increased risk for late repair failure.