Leaflet Reconstructive Techniques for Aortic Valve Repair
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The most commonly encountered cusp defect is leaflet prolapse. Two-thirds involve the isolated right coronary cusp, and the remainder are equally divided between isolated noncoronary, isolated left coronary, and multileaflet prolapse. After aortic ring annuloplasty, prolapse is corrected with symmetrical peri-Nodular leaflet plication, normalizing leaflet effective height and coaptation area. Around one-fourth of patients have Nodular retraction, and Nodular release is performed with a CUSA ultrasonic device. If calcium involves less than 25% of the leaflet, ultrasonic decalcification also can be applied. Structural leaflet defects, such as commissural rupture, holes, or extensive fenestrations, are observed in 20%. These are reconstructed with double layers of glutaraldehyde-fixed autologous pericardium, using fine vertical mattress sutures. In extreme cases, leaflets are replaced with autologous pericardium, using the algorithm: leaflet free-edge length = reconstructed annular diameter times 1.5.
Leaflet plication has been effective and stable in prolapse correction, with a negligible incidence of failure. Ultrasonic Nodular release and pericardial reconstruction also have been highly successful long-term. In combination with aortic ring annuloplasty, these leaflet techniques provide an effective method of AVr.
When performing AVr for significant AI, leaflet defects are common. Techniques for cusp repair using central plication, limited decalcification or Nodular release, and autologous pericardium, when combined with ring annuloplasty, afford a simple and comprehensive system for AVr.