Impact of Postoperative Annular Diameter on Mid-term Outcomes of Aortic Valve Repair

Background: A normal function of the aortic valve after repair can be only achieved by simultaneous restoration of normal aortic root dimensions and cusp geometry. Ventriculoaortic junction (VAJ) diameter and effective cusp height have been reported to predict the outcome after aortic valve repair procedures. We aimed to analyze the impact of postoperative VAJ diameter on functional outcomes after aortic valve repair in a consecutive cohort of patients during the past 3 years.

Methods: All consecutive patients undergoing elective aortic valve repair at our institution from January 2016 to July 2018 were prospectively included. Seventy-four patients (56%) underwent aortic valve repair via partial upper sternotomy. Transthoracic echocardiography was performed at discharge, at 6 months, 1, and 2 years after surgery. Systematic echocardiographic measurements were performed before and after aortic valve repair: annular (VAJ) diameter in mid-systole and effective cusp height in end diastole. Primary end point was freedom from AR ≥ 2 and secondary end points were freedom from redo surgery and prosthetic valve replacement.

Results: A total of 132 consecutive patients underwent aortic valve repair during the study period at our institution (mean age 47 ± 14 years, 76% male). Mean postoperative VAJ diameter (at hospital discharge) was 24.03 ± 3.3 mm, and effective cusp height was 11.05 ± 2.4 mm. Freedom of AR ≥ 2, aortic valve redo surgery, and prosthetic valve replacement at follow-up was 96, 99, and 100% in patients with postoperative VAJ ≤ 25 mm versus 81, 89, and 92% in patients with postoperative VAJ > 25 mm, respectively. Kaplan–Meier estimator showed a significant higher recurrence rate of AR ≥ 2 (p = 0.033), redo aortic valve surgery (p = 0.020) and redo prosthetic valve replacement (p = 0.011) in the VAJ > 25 mm group. Postoperative VAJ ≤ 25 mm was found to be protective against AR ≥ 2 recurrence (odds ratio [OR]: 0.230; p = 0.012) and redo aortic valve surgery (OR: 0.489; p = 0.026) in the logistic regression analysis. Post hoc analysis showed that VAJ ≤ 25 mm could be similarly often achieved in the conventional sternotomy versus partial upper sternotomy subgroups (i.e., 62 vs. 73%, p = 0.193).

Conclusion: We found that postoperative VAJ diameter above 25 mm is a risk factor for repair failure after aortic valve sparing procedures. Appropriate VAJ stabilization can be reproducibly achieved via a partial upper sternotomy.