Aortic valve reconstruction in myxomatous degeneration of aortic valves: are fenestrations a risk factor for repair failure?

Objective: Aortic valve repair is a more recent approach for the treatment of aortic regurgitation. Limited data exist for reconstruction in specific pathologies with isolated cusp pathology. We analyzed the results of aortic valve repair in patients with aortic regurgitation caused by myxomatous cusp prolapse in the presence of tricuspid valve anatomy and normal root size.

Methods: Over a 12-year period, 111 patients underwent aortic valve reconstruction for regurgitant tricuspid aortic valves without concomitant root dilatation. Cusp prolapse was caused by myxomatous degeneration in 72 subjects (group I) and associated with fenestrations in 39 subjects (group II). Prolapse was corrected by means of plication of the free margin in the presence of normal cusp tissue only (n = 62) or combined with triangular resection of cusp tissue (n = 10). It was treated with additional closure of the fenestration with autologous pericardium in 39 instances (group II). Follow-up was complete in 98.5% (cumulative 385 years).

Results: Hospital mortality was 1.8%, and during follow-up, there was 1 thromboembolic event and no endocarditis. Freedom from reoperation at 5 and 8 years was 96%.

Conclusions: Isolated cusp prolapse is a relevant cause of aortic regurgitation in tricuspid aortic valves without concomitant root dilatation. In myxomatous stretching of cusp tissue, plication of the free margin suffices to restore cusp geometry and aortic valve function. In the presence of fenestrations, reconstruction of normal cusp configuration can be achieved by means of closure of the fenestration with a pericardial patch. The midterm stability of both approaches is good.