Preoperative Eccentric Aortic Regurgitation and Outcomes Following Valve-Sparing Root Replacement

OBJECTIVE: The David V valve-sparing root replacement (VSRR) is well-established for the treatment of AI and advanced root aortopathy. The impact of cusp repair in trileaflet aortic valve (TAV) patients, however, with preoperative moderate-severe AI and an eccentric jet is unclear. This study compares postoperative outcomes and the long-term cumulative incidence of recurrent AI >1+ and valve specific re-intervention in TAV patients with pre-operative AI >2+ based on jet centricity and cusp repair status. METHODS: Review of a single institutional database identified 309 consecutive patients undergoing VSRR from 2005–2018. Of these, 51 patients had a TAV with AI >2+: 25 concentric and 26 eccentric jets. Mean follow-up was 58 (SD=44) months. Echocardiographic parameters were compared between pre- and post-operative echocardiogram. Kaplan-Meier analysis and cumulative incidence were used to compare long-term survival, recurrence of AI >1+, and valve specific re-intervention. RESULTS: The mean age was 48 (SD=12) years and 84% were male. Differences in preoperative comorbidities or echocardiographic parameters between groups were not statistically significant. Concentric and eccentric patients underwent cusp repair at 48.0% vs. 57.7%, p=0.49. Postoperative outcomes were similar in concentric vs. eccentric undergoing cusp repair. On chest closure TEE, 98% of patients had AI < 1+, and no patients had AI >2+. Cumulative incidence for recurrence of AI >1+ and AVR were 0% for central and 4%, 9%, and 16% for eccentric at 3-, 5-, and 10-years and 0% for central and 5% for eccentric at 3-, 5-, and 10-years, respectively. Long-term mortality was similar regardless of jet centricity and cusp repair. CONCLUSIONS: In selected TAV patients with preoperative AI >2+, VSRR provides a durable repair regardless of jet centricity. The addition of cusp repair did not negatively impact recurrent AI >1+ or rates of valve related re-intervention.