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A lesional classification to standardize surgical management of aortic insufficiency towards valve repair

^a Assistance Publique Hopitaux de Paris (APHP), The Department of Cardiovascular and Thoracic Surgery, Bichat and Pitie Salpetriere University Hospital, Paris, France
^b Assistance Publique Hopitaux de Paris (APHP), The Department of Vascular Surgery, Ambroise Paré University Hospital, Boulogne Billancourt, France
^c The Department of Cardiology, Marie Lannelongue Hospital, Le Plessis Robinson, France
^d Assistance Publique Hopitaux de Paris (APHP), The Department of Cardiovascular and Thoracic Surgery, Pitie Salpetriere University Hospital, Paris, France

Received 19 September 2007; received in revised form 26 November 2007; accepted 3 December 2007.

^_* Corresponding author. Address: Department of Cardiovascular and Thoracic Surgery, Bichat University Hospital, 46 Rue Henri Huchard, 75018 Paris Cedex, France. Tel.: +33 1 40 25 67 02; fax: +33 1 40 25 67 00. (Email: emmanuel.lansac{at}bch.aphp.fr).

Objective: Aortic valve repair is an alternative to valve replacement for treatment of chronic aortic insufficiency (AI). In order to standardize surgical management, we suggest a classification based on echocardiographic and operative analysis of valvular lesions. Methods: Classification was based on the retrospective analysis of chronic AI mechanisms of 781 adults operated on electively between 1997 and 2003. Results: AI was isolated (406 patients (52%)), associated with supra-coronary aneurysm (97 cases (12.4%)), or with aortic root aneurysm (278 patients (35.6%)). Etiologies of valvular or aortic lesions were respectively rheumatic, dystrophic and atheromatous in 17%, 73.6% and 9.4% of cases. Lesional classification is based on the analysis of chronic AI mechanisms defining type I with central jet (354 cases, 45.3%) and type II with eccentric jet (54.7%). Type Ia is defined as isolated dilation of sino-tubular junction (47 supra-coronary aneurysms), and type Ib as dilation of both sino-tubular junction and aortic annular base (233 root aneurysms, 74 isolated AI). The type II associates dilation of sino-tubular junction and annular base to a valvular lesion: IIa cusp prolapse (95 aneurysms, 200 isolated AI); IIb cusp retraction (132 rheumatic AI), IIc cusp tear (endocarditis, traumatic). Conclusion: A lesional classification aims to standardize the surgical management of aortic valve repair: type Ia, by supra-coronary graft; type Ib, by subvalvular aortic annuloplasty associated with the aortic root replacement with a remodelling technique (root aneurysm) or double sub- and supravalvular annuloplasty (isolated AI). For chronic AI type II, aortic annuloplasty associated a remodelling technique or double sub- and supravalvular annuloplasty is combined with the treatment of the cusp lesion (cusp resuspension, cusp reconstruction with autologous pericardium).

Key Words: Aortic valve repair • Aortic annuloplasty • Chronic aortic insufficiency • Aortic root aneurysm • Valvuloplasty • Lesional classification

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