VALVE REPAIR FOR AORTIC-INSUFFICIENCY - SURGICAL CLASSIFICATION AND TECHNIQUES

Objective: Valve repair for aortic insufficiency may provide an altern ative to aortic valve replacement in selected patients. This repair co uld be an attempt at permanent correction or palliation to allow the a ortic annulus to grow and avoid the use of anticoagulation. Based upon a five-year experience, we proposed a classification according to val vular anatomy which could be a guide to patient and procedure selectio n Methods: Between September 1989 and February 1995, 44 consecutive pa tients underwent aortic valvuloplasty for aortic incompetence at our i nstitution. Patients' ages ranged from 19 months to 76 years with a me an of 33 years. The etiology of aortic incompetence was congenital in 30 patients, degenerative in 7 patients, rheumatic in 5 patients, and infective endocarditis in 2. Aortic Valve lesions were classified into three different types: type I, aortic annular dilatation (8 patients) ; type II, excessive aortic leaflet tissue (12 patients); and type III , restricted leaflet motion with or without deficient leaflet tissue ( 24 patients). Type I needed commissural plication in 7 patients; and a ortic annuloplasty, which was simple in 6 patients, and pericardial-au gmented in 2. Type II necessitated midleaflet excision in 11 patients and leaflet plication in 7. Type III required leaflet extension in 19 patients, leaflet replacement in 1 patient, aortic valve commissurotom y in 13 patients, augmentation commissurorrhaphy in 2, leaflet shaving in 4, and repair of leaflet perforation in 2. Results: Postoperative echocardiography revealed a significant decrease in the degree of aort ic incompetence. Mean follow-up was 2.6 +/- 1.4 years. There was no mo rtality. Patients improved as is evident by NYHA functional class post operatively. Eight of the first 13 patients (18%) needed reoperation. Three of these reoperations were bail-out procedures, and 3 patients ( 7%) who underwent the leaflet extension technique were reoperated upon 19 months to 3 years later. Presently, 23 patients are without antico agulation, Il take aspirin and 2 receive coumadin for combined mitral procedures. Conclusions: Aortic valve repair provides a low risk optio n with satisfactory intermediate-term results for the treatment of aor tic insufficiency in appropriately selected patients. Patient and proc edure selection may be based upon the echocardiographic anatomy of the aortic valve, and a comparative risk benefit appraisal with valve rep lacement. (C) 1997 Elsevier Science B.V.