Aortic valve reconstruction

Reconstruction of the aortic valve is not as widespread as reconstruction of the mitral valve but is becoming increasingly important. Insufficiency (inability to close properly) is most suitable for reconstruction of the aortic valve. The reason for the insufficiency may be within the valve itself, affecting the semilunar cusps and the ring or annulus, e.g. a bicuspid valve, or may be due to changes in the root of the aorta, e.g. an increase in the size of the aorta due to an aneurysm.

The advantage of reconstruction is that the patient’s own valve is preserved. If the heart rhythm is stable, taking anticoagulant drugs such as warfarin can then be unnecessary.

A precondition for reconstruction is the most accurate possible knowledge of the valve and aortic root, which can best be obtained by transoesophageal echo. Particular attention is paid to the mobility of the individual semilunar cusps and the commissures between them. For example, calcifications can be identified. The diameter of the valve annulus is measured, as is the width of the aortic root and the diameter at the junction with the aorta (sinotubular junction). Further measurements, e.g. pressures in the ventricles, are provided by cardiac catheterisation. The operative procedure can be planned from analysis of the investigation results. The aim of reconstruction is to restore anatomical and physiological conditions. This can be achieved by the following procedures:

Corrections of the valve cusps

• Plication (“tucking”) of sagging semilunar cusps
• Resection, e.g. cutting a triangle out of excess valve tissue
• Cusp replacement where there is too little tissue by suturing in a pericardial patch
• “Sealing“ a perforation in a cusp by means of a tissue patch
• Stabilisation of the commissures (suspension of the valves of the aortic wall) by suture

Corrections of the aortic root

Both widening (dilatation) of the aortic valve annulus and a sac-like bulge (aneurysm) of the aortic root with separation of the commissures lead to insufficiency when the valve cusps are otherwise intact.

Restoration of a fully closing valve in these cases can be achieved only by implantation of a vascular prosthesis. Either the aneurysm is replaced to restore the normal width of the aortic root (remodelling) or the aortic valve annulus is also restored to a normal size (reimplantation). These operations are known in the literature as Yacoub or David operations. In both cases, the origins of the coronary arteries have to be sutured to the prosthesis.

Reconstructed valves must be monitored at regular intervals following surgery by means of echocardiography.