Commentary: Aortic valve repair: How much is too much?

Abstract

Central MessageComplex aortic valve repair can be performed for rare aortic valve congenital anomalies with acceptable short-term results, but long-term results are unknown.See Article page 69. Complex aortic valve repair can be performed for rare aortic valve congenital anomalies with acceptable short-term results, but long-term results are unknown. See Article page 69. Motoki and colleagues1Motoki T. Ikeno Y. Suehiro Y. Kurushima A. Okita Y. Fukumura Y. A successful repair of pentacuspid aortic valve.J Thorac Cardiovasc Surg Tech. 2022; 14: 69-72Scopus (1) Google Scholar present a case of a rare congenital anomaly, pentacuspid aortic valve, in a 52-year-old patient who underwent cusp repair with tricuspidization and aortic root remodeling. The authors are to be congratulated for a good outcome and on their previous work on complex aortic valve repair.2Ikeno Y. Yamanaka K. Tanaka H. Okita Y. Aortic valve repair with valve-sparing root replacement for asymmetric quadricuspid aortic valve and conversion into symmetric tricuspid valve.J Thorac Cardiovasc Surg. 2019; 158: e25-e27https://doi.org/10.1016/j.jtcvs.2019.02.035Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar This was performed on a 52-year-old woman with severe aortic regurgitation and a normal aortic root. Follow-up at 3 years demonstrated mild central aortic regurgitation with improved left ventricular remodeling. This case is essentially a proof-of-concept exercise and adds to the growing amount of literature regarding aortic valve repair.3Sultan I. Komlo C. Bavaria J.E. How I teach a valve-sparing root replacement.Ann Thorac Surg. 2016; 101: 422-425Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar Recognizing the cons of both lifelong anticoagulation and the inevitable structural valve degeneration of bioprosthetic valves, there is understandably growing interest in aortic valve–sparing techniques. With as rare of a condition as pentacuspid aortic valve is, it is challenging to imagine that the specific technique will have a profound change in the big picture of aortic valve sparing operations. Nevertheless, this case demonstrates that with adherence to the principles of restoring cusp coaptation, and stabilization of the aortic annulus and sinotubular junction complex repair can be performed with adequate short-term results in selected patients. However, while surgeons may be able to repair most aortic valves with pure regurgitation, the ability to repair versus reassure patients of valve repair durability are 2 very distinct points. Most reports on long-term valve repair data are self-selected, and even bicuspid valve-sparing root reimplantation typically forms a small percentage of the valve-sparing root reimplantation cohorts.4Arnaoutakis G.J. Sultan I. Siki M. Bavaria J.E. Bicuspid aortic valve repair: systematic review on long-term outcomes.Ann Cardiothorac Surg. 2019; 8: 302-312Crossref PubMed Scopus (18) Google Scholar,5Ouzounian M. Feindel C.M. Manlhiot C. David C. David T.E. Valve sparing root replacement in patients with bicuspid versus tricuspid aortic valves.J Thorac Cardiovasc Surg. 2019; 158: 1-9Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar For readers to take away that complex aortic valve repair translates to long-term durability would be misleading. In cases in which the cusps have significant calcifications, numerous fenestrations or cusp restriction, or immobility related to rheumatic disease, durable repair of the valve would be unlikely. The repair may fail in the long term with stenosis or regurgitation or a combination of both. Replacement of a pentacuspid valve is a reliable, proven treatment and in the hands of almost all surgeons can be the right choice. No matter the mid- and long-term outcome of this particular patient, the rarity of the disease makes it unlikely that any conclusions can be drawn from this endeavor other than technical safety and feasibility. The eventual results of the PROACT Xa trial, if they demonstrate safe maintenance of anticoagulation with apixiban, will have significant effects on the future of aortic valve interventions operations in patients who have unfavorable anatomy for durable aortic valve repair and freedom from aortic valve reintervention.6Jawitz O.K. Wang T.Y. Lopes R.D. Chavez A. Boyer B. Kim H. et al.Rationale and design of PROACT Xa. A randomized, multicenter, open-label, clinical trial to evaluate the efficacy and safety of apixaban versus warfarin in patients with a mechanical On-X aortic heart valve.Am Heart J. 2020; 227: 91-99Crossref PubMed Scopus (19) Google Scholar The ability to avoid warfarin anticoagulation with a mechanical valve could be a “game changer” in the aortic valve space and would likely lower the threshold for the use of mechanical prostheses in the aortic position for such patients. A successful repair of pentacuspid aortic valveJTCVS TechniquesVol. 14PreviewPentacuspid aortic valve (PAV) is an extremely rare congenital cardiac anomaly.1 Simonds2 first described PAV in 1923; subsequently, 8 cases, including 5 treated with aortic valve replacement, have been reported. Aortic valve replacement is the standard treatment for PAV-related aortic regurgitation (AR); there have been no reports of aortic valve repair in PAV. 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