Aortic valve repair and aortic valve–sparing operations

Abstract

Attempts to correct aortic insufficiency by means of aortic valve repair started soon after the advent of open-chest cardiac surgery. Correction of cusp prolapse was performed by suturing the free margins of 2 cusps from the commissures to the central portion or by excising the noncoronary aortic cusp and sinus, transforming a tricuspid into a bicuspid aortic valve. In the early days of cardiac surgery, aortic cusp extension with fascia lata was also done to correct aortic insufficiency. The lack of adequate imaging of the aortic valve limited the application of these techniques and the development of new ones. Echocardiography changed all that and had a dramatic effect on our ability to examine the aortic valve, select patients for aortic valve repair, and assess valve function intraoperatively and postoperatively. The aortic valve is better described as a unit, the aortic root, which is made of various components. The aortic cusps are certainly the most important, but the aortoventricular junction, the aortic sinuses, and the sinotubular junction also play a role in how the cusps open without obstruction during systole or and close without leakage during diastole. The phrase ‘‘form follows function’’ is certainly applicable to the aortic root, and although we have learned a great deal regarding how the various components of the aortic root interact, there is still a lot to be learned. As a student of the aortic root, I have been surprised by the variability in physical appearance of aortic root in individuals with normally functioning aortic valve as well as before and after operations that preserve the native aortic cusps. Years ago, Feindel and I coined the term aortic valve– sparing operations to describe conservative procedures on the aortic valve in patients with aortic root or ascending aortic aneurysms. A few years later, we classified aortic valve–sparing operations into 2 subgroups, aortic valve reimplantation and aortic root remodeling. This new surgical nomenclature was an attempt to define the various types of operative procedures that we used to preserve the aortic