Repair of aortic leaflet prolapse: a ten-year experience

Objective: Leaflet plication (PL), triangular resection (TR), resuspension with running suture of Gore-Tex (GTx) and extension with autologous pericardial patch (PP) are different techniques to repair aortic leaflet prolapse (LP) for aortic insufficienty (Al). In this study, we report and compare the early and mid-term results of these techniques for aortic valve repair. Methods: From 1996 to 2006, 298 patients underwent elective aortic valve (AV) repair. In 146 of them, prolapse of one (n = 72) or more than one leaflet (n = 74) was found. LP was defined either as a longer or lower leaflet free margin compared to the other leaflet(s) or a relatively low coaptation level of all leaflets. When leaflet tissues were of good quality (thin and pliable), prolapse was treated by GTx (n = 39), PL (n = 25) of GTx + PL (n = 23). When leaflet tissues were of poor quality (thickened, calcified), prolapse was treated by TR or PP (n = 13) or TR or PP + GTx (n = 47). Results: There was no hospital mortality. During the initial hospitalization two patients required reoperation for recurrent Al and one for aorto-right ventricular fistula; of them, two were re-repaired. Median follow-up was 35 months (range 9-136). Three patients needed late reoperation for recurrent Al. At 4 years, overall survival was 99 +/- 1% and freedom from reoperation and from recurrent Al (grade > 2) was 94 +/- 5% and 91 +/- 7% respectively. Freedom from recurrent Al was similar in patients having one versus more than one LP repair (88 +/- 11% vs 92 +/- 8%, p = 0.2) and among the different techniques used to repair leaflet of good quality (PL: 95 +/- 8% vs GTx: 83 +/- 18% vs PL + GTx: 100%; p = 0.37). When leaflet resection was needed, the addition of GTx significantly reduced the recurrence of Al (TR or PP: 82 +/- 18% vs TR or PP + GTx: 97 +/- 4%; p = 0.026). Conclusions: Leaflet plication and Gore-Tex resuspension are both effective and durable techniques for aortic leaflet proplase repair. The addition of Gore-Tex to triangular resection and pericardial patch repair techniques is efficient to reinforce the suture line and to improve the outcome of the repair. Multiple leaflet prolapse is not a prohibitive factor for successful repair even in the absence of a clear reference level such as a normal leaflet, as long as normal anatomical coaptation is achieved. (C) 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.