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Clinical outcomes and lessons learned with aortic valve repair in 508 patients.

BACKGROUND AND AIM OF THE STUDY
Aortic valve repair is an attractive alternative to valve replacement. Herein is presented the authors' single-center experience and lessons learned from 508 patients undergoing AVR, in three different groups.


METHODS
Between 1993 and 2010, a total of 508 patients (148 females, 360 males; mean age 54 ± 17 years) underwent aortic valve repair. Operations included valve-sparing surgery (n = 253), isolated leaflet intervention (n = 158), and sinotubular junction (STJ) remodeling (n = 97). Aortic valve repair was defined as any primary or concomitant procedure performed at the level of the aortic valve or root for the restoration of function and/or anatomy of the valve. The mean follow up was 6.9 ± 3.8 years (range: 0-18 years; median: 6.3 years; total: 3,477 patient-years). The completeness of clinical follow up was 95%.


RESULTS
The 30-day mortality with and without dissection was 4.4% (8/180) and 1.8% (6/328), respectively. Late survival without dissection, although statistically inferior, followed closely the expected general population. In total, 53 patients required a cardiac, valve-related reoperation. Among the valve-sparing group, no significant difference in freedom from reoperation at 10 years was observed between the David and Yacoub types (n = 147 (89%) versus n = 113 (79%); p = 0.373, respectively). Among patients who underwent isolated leaflet interventions, the number required to restore valve function (repair score) significantly affected the durability and incidence of reoperations (hazard ratio 1.47; 95% CI 1.1-2.0; p = 0.01), with the risk for failure being higher early after the operation. Patients with functional aortic insufficiency (AI) requiring only STJ remodeling resulted in the most durable outcome (freedom from reoperation 97.5% at 10 years). At the latest echocardiographic follow up (448 patients; total: 2,755 pt-yr; mean: 6.4 ± 3.7 years; completeness 88%), 97% of patients had AI of grade ≤ 2.


CONCLUSION
Aortic valve repair is an attractive alternative to conventional replacement in many patients and pathologies. In particular, pathologies requiring multiple leaflet interventions and repair techniques may lead to suboptimal results. Leaflet quality and leaflet-adjusted root stabilization/reconstruction are key elements for durable results.