Aortic cusp sizers to establish the functional classification of aortic insufficiency: algorithm and midterm outcome of operative repair

OBJECTIVES: Wider adoption of aortic valve repair procedures is held up by the difficulty in recognizing the exact alterations that are responsible for aortic valve insufficiency. New aortic cusp sizers were developed to assist in aortic valve assessment in the operating theatre. Our objectives were to examine the efficacy of the aortic cusp sizers in establishing the functional classification of aortic valve insufficiency, and to report the midterm outcome in a group of patients who had undergone aortic valve repair guided by this device. METHODS: A prospective clinical study was performed involving 33 consecutive patients (18 males, age range: 8-74 years) with severe aortic valve insufficiency (mean severity: 3.4 +/- 0.5). The aortic cusp sizers were used as a template to identify existing cusp and root alterations. Consequently, the functional classification of aortic insufficiency was determined, and the appropriate techniques of aortic valve repair were implemented. RESULTS: Aortic valve repair was successful in all patients. Procedures performed were 37 functional aortic annulus corrections, 9 cusp free-edge plications, 2 cusp repairs with autologous pericardium, 9 replacements of the ascending aorta and 2 reimplantation procedures. At a mean follow-up time of 18.3 +/- 13.7 months, 1 patient underwent aortic valve replacement for recurrent aortic valve regurgitation, while aortic valve function remained stable in 32 patients, with aortic insufficiency < 1+ in 27 (84.4%) patients and 1-1.5 in 5 (15.6%) patients, and no significant gradients across the aortic valves. CONCLUSIONS: The aortic cusp sizers are valuable in establishing the functional classification of aortic insufficiency, and can guide implementation of aortic valve repair techniques successfully. This approach is analogous to that accredited for the success and wide adoption of mitral valve repair techniques, and is likely to assist in increasing the percentage of aortic valves that are repaired when compared with current practice.