Journal of Medical Ultrasonics

, Volume 46, Issue 1, pp 51–62 | Cite as

Aortic valve repair for aortic regurgitation and preoperative echocardiographic assessment

  • Takashi KuniharaEmail author
Review Article


Aortic valvuloplasty (AVP) has been performed less frequently than mitral valvuloplasty. The survival benefit of AVP over replacement has been demonstrated. Therefore, standardization of AVP is crucial for its widespread adoption. The hemodynamic advantage of AVP of preserving the native aortic valve may be one reason for the survival benefit. Recent guidelines still recommend AVP in selected cases compared with the less restricted recommendation for mitral valvuloplasty, although recent studies have proposed earlier indication for surgical intervention. Indication for aortic root replacement is also still conservative, especially in Japan. However, more liberal root replacement should be recommended for better repair when AVP is indicated. Theoretically, all aortic regurgitation lesions can be repaired with acceptable durability. However, restricted cusp should be extended by a pericardial patch, which itself has emerged as a risk of recurrence. Therefore, indications for aortic regurgitation for type III lesions should be determined carefully. Special consideration is crucial for bicuspid aortic valve repair; prevention of postoperative stenosis is especially important. Arrangement of the commissure position is the most important consideration for this purpose, although it remains controversial. Therefore, detailed diagnosis is important in planning AVP, and echocardiography plays a key role in this process.


Aortic valve repair Valve-preserving root replacement Echocardiography Surgical indication Operative technique 



The author would like to thank Dr. Miura, Shizuoka City Shizuoka Hospital, and Dr. Hama, Saku Central Hospital Advanced Care Center, for sharing intraoperative and echocardiographic findings.

Compliance with ethical standards

Conflict of interest

The author declares that there are no conflicts of interest related to this study.


  1. 1.
    Committee for Scientific Affairs, The Japanese Association for Thoracic Surgery, Masuda M, Okumura M, Doki Y, et al. Thoracic and cardiovascular surgery in Japan during: annual report by the Japanese Association for Thoracic Surgery. Gen Thorac Cardiovasc Surg. 2014;2016(64):665–97.Google Scholar
  2. 2.
    Iung B, Baron G, Butchart EG, et al. A prospective survey of patients with valvular heart disease in Europe: the Euro heart survey on valvular heart disease. Eur Heart J. 2003;24:1231–43.CrossRefGoogle Scholar
  3. 3.
    Beckmann A, Funkat AK, Lewandowski J, et al. German heart surgery report 2015: the annual updated registry of the German society for thoracic and cardiovascular surgery. Thorac Cardiovasc Surg. 2016;64:462–74.CrossRefGoogle Scholar
  4. 4.
    Stamou SC, Williams ML, Gunn TM, et al. Aortic root surgery in the United States: a report from the society of thoracic surgeons database. J Thorac Cardiovasc Surg. 2015;149(116–22):e4.Google Scholar
  5. 5.
    Committee for Scientific Affairs, The Japanese Association for Thoracic Surgery, Masuda M, Kuwano H, Okumura M, et al. Thoracic and cardiovascular surgery in Japan during, annual report by The Japanese association for thoracic surgery. Gen Thorac Cardiovasc Surg. 2012;2014(62):734–64.Google Scholar
  6. 6.
    Arimura S, Seki M, Sasaki K, et al. A nationwide survey of aortic valve surgery in Japan: current status of valve preservation in cases with aortic regurgitation. Gen Thorac Cardiovasc Surg. 2017;65:429–34.CrossRefGoogle Scholar
  7. 7.
    Schäfers HJ, Bierbach B, Aicher D. A new approach to the assessment of aortic cusp geometry. J Thorac Cardiovasc Surg. 2006;132:436–8.CrossRefGoogle Scholar
  8. 8.
    Boodhwani M, de Kerchove L, Glineur D, et al. Repair-oriented classification of aortic insufficiency: impact on surgical techniques and clinical outcomes. J Thorac Cardiovasc Surg. 2009;137:286–94.CrossRefGoogle Scholar
  9. 9.
    Malas T, Saczkowski R, Sohmer B, et al. Is aortic valve repair reproducible? Analysis of the learning curve for aortic valve repair. Can J Cardiol. 2015;31:1497.e15–22.CrossRefGoogle Scholar
  10. 10.
    Kunihara T. Toward standardization of valve-sparing root replacement and annuloplasty. Gen Thorac Cardiovasc Surg. (in press).Google Scholar
  11. 11.
    de Meester C, Pasquet A, Gerber BL, et al. Valve repair improves the outcome of surgery for chronic severe aortic regurgitation: a propensity score analysis. J Thorac Cardiovasc Surg. 2014;148:1913–20.CrossRefGoogle Scholar
  12. 12.
    Ouzounian M, Rao V, Manlhiot C, et al. Valve-sparing root replacement compared with composite valve graft procedures in patients with aortic root dilation. J Am Coll Cardiol. 2016;68:1838–47.CrossRefGoogle Scholar
  13. 13.
    Forcillo J, Pellerin M, Perrault LP, et al. Carpentier-Edwards pericardial valve in the aortic position: 25 years experience. Ann Thorac Surg. 2013;96:486–93.CrossRefGoogle Scholar
  14. 14.
    Mookhoek A, Korteland NM, Arabkhani B, et al. Bentall procedure: a systematic review and meta-analysis. Ann Thorac Surg. 2016;101:1684–9.CrossRefGoogle Scholar
  15. 15.
    Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation. 1978;58:20–4.CrossRefGoogle Scholar
  16. 16.
    Graeter TP, Fries R, Aicher D, Reul H, Schmitz C, Schäfers HJ. In-vitro comparison of aortic valve hemodynamics between aortic root remodeling and aortic valve reimplantation. J Heart Valve Dis. 2006;15:329–35.Google Scholar
  17. 17.
    Zeeshan A, Idrees JJ, Johnston DR, Rajeswaran J, Roselli EE, Soltesz EG, Gillinov AM, Griffin B, Grimm R, Hammer DF, Pettersson GB, Blackstone EH, Sabik JF 3rd, Svensson LG. Durability of aortic valve cusp repair with and without annular support. Ann Thorac Surg. 2018;105:739–48.CrossRefGoogle Scholar
  18. 18.
    Thudt M, Papadopoulos N, Monsefi N, Miskovic A, Karimian-Tabrizi A, Zierer A, Moritz A. Long-Term results following pericardial patch augmentation for incompetent bicuspid aortic valves: a single center experience. Ann Thorac Surg. 2017;103:1186–92.CrossRefGoogle Scholar
  19. 19.
    Vohra HA, Whistance RN, de Kerchove L, et al. Influence of higher valve gradient on long-term outcome after aortic valve repair. Ann Cardiothorac Surg. 2013;2:30–9.Google Scholar
  20. 20.
    Nishimura RA, Otto CM, Bonow RO, ACC, AHA Task Force Members, et al. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: executive summary: a report of the American college of cardiology/american heart association task force on practice guidelines. Circulation. 2014;2014(129):2440–92.CrossRefGoogle Scholar
  21. 21.
    Falk V, Baumgartner H, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Muñoz DR, Rosenhek R, Sjögren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL, ESC Scientific Document Group. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2017;52:616–64.CrossRefGoogle Scholar
  22. 22.
    Chaliki HP, Mohty D, Avierinos JF, Scott CG, Schaff HV, Tajik AJ, Enriquez-Sarano M. Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function. Circulation. 2002;106:2687–93.CrossRefGoogle Scholar
  23. 23.
    Sharma V, Suri RM, Dearani JA, Burkhart HM, Park SJ, Joyce LD, Li Z, Schaff HV. Expanding relevance of aortic valve repair-is earlier operation indicated? J Thorac Cardiovasc Surg. 2014;147:100–7.CrossRefGoogle Scholar
  24. 24.
    Tornos P, Sambola A, Permanyer-Miralda G, et al. Long-term outcome of surgically treated aortic regurgitation: influence of guideline adherence toward early surgery. J Am Coll Cardiol. 2006;47:1012–7.CrossRefGoogle Scholar
  25. 25.
    Brown ML, Schaff HV, Suri RM, et al. Indexed left ventricular dimensions best predict survival after aortic valve replacement in patients with aortic valve regurgitation. Ann Thorac Surg. 2009;87:1170–5.CrossRefGoogle Scholar
  26. 26.
    Wang Y, Shi J, Li F, et al. Aortic valve replacement for severe aortic regurgitation in asymptomatic patients with normal ejection fraction and severe left ventricular dilatation. Interact Cardiovasc Thorac Surg. 2016;22:425–30.CrossRefGoogle Scholar
  27. 27.
    ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease representative members, 2014 AHA/ACC guideline for the management of patients with valvular heart disease representative members, Nishimura RA, Bonow RO, Guyton RA, Hiratzka LF, Creager MA, Isselbacher EM, et al. Surgery for aortic dilatation in patients with bicuspid aortic valves: a statement of clarification from the American college of cardiology/american heart association task force on clinical practice guidelines. J Thorac Cardiovasc Surg. 2016;151:959–66.CrossRefGoogle Scholar
  28. 28.
    Erbel R, Aboyans V, Boileau C, ESC Committee for Practice Guidelines, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the european society of cardiology (ESC). Eur Heart J. 2014;35:2873–926.CrossRefGoogle Scholar
  29. 29.
    Guidelines for surgical and interventional treatment of valvular heart disease JCS 2012.
  30. 30.
    JCS Joint Working Group. Guidelines for diagnosis and treatment of aortic aneurysm and aortic dissection (JCS 2011): digest version. Circ J. 2013;77:789–828.CrossRefGoogle Scholar
  31. 31.
    de Kerchove L, Boodhwani M, Glineur D, et al. Valve sparing-root replacement with the reimplantation technique to increase the durability of bicuspid aortic valve repair. J Thorac Cardiovasc Surg. 2011;142:1430–8.CrossRefGoogle Scholar
  32. 32.
    Aicher D, Kunihara T, Abou Issa O, et al. Valve configuration determines long-term results after repair of the bicuspid aortic valve. Circulation. 2011;123:178–85.CrossRefGoogle Scholar
  33. 33.
    Navarra E, El Khoury G, Glineur D, et al. Effect of annulus dimension and annuloplasty on bicuspid aortic valve repair. Eur J Cardiothorac Surg. 2013;44:316–22.CrossRefGoogle Scholar
  34. 34.
    Kunihara T, Aicher D, Rodionycheva S, et al. Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valve-preserving aortic root repair. J Thorac Cardiovasc Surg. 2012;143:1389–95.CrossRefGoogle Scholar
  35. 35.
    Schäfers HJ, Schmied W, Marom G, et al. Cusp height in aortic valves. J Thorac Cardiovasc Surg. 2013;146:269–74.CrossRefGoogle Scholar
  36. 36.
    Asano M, Kunihara T, Aicher D, et al. Mid-term results after sinutubular junction remodelling with aortic cusp repair. Eur J Cardiothorac Surg. 2012;42:1010–5.CrossRefGoogle Scholar
  37. 37.
    David TE, Feindel CM, Armstrong S, et al. Replacement of the ascending aorta with reduction of the diameter of the sinotubular junction to treat aortic insufficiency in patients with ascending aortic aneurysm. J Thorac Cardiovasc Surg. 2007;133:414–8.CrossRefGoogle Scholar
  38. 38.
    Pethig K, Milz A, Hagl C, et al. Aortic valve reimplantation in ascending aortic aneurysm: risk factors for early valve failure. Ann Thorac Surg. 2002;73:29–33.CrossRefGoogle Scholar
  39. 39.
    David TE, Feindel CM. An aortic-valve sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 1992;103:617–22.Google Scholar
  40. 40.
    Sarsam MA, Yacoub M. Remodeling of the aortic anulus. J Thorac Cardiovasc Surg. 1993;105:435–8.Google Scholar
  41. 41.
    Shimizu H, Yozu R. Valve-sparing aortic root replacement. Ann Thorac Cardiovasc Surg. 2011;17:330–6.CrossRefGoogle Scholar
  42. 42.
    Morishita K, Murakami G, Koshino T, et al. Aortic root remodeling operation: how do we tailor a tube graft? Ann Thorac Surg. 2002;73:1117–21.CrossRefGoogle Scholar
  43. 43.
    Fries R, Graeter T, Aicher D, et al. In vitro comparison of aortic valve movement after valve-preserving aortic replacement. J Thorac Cardiovasc Surg. 2006;132:32–7.CrossRefGoogle Scholar
  44. 44.
    Cabrol C, Cabrol A, Guiraudon G, et al. Treatment of aortic insufficiency by means of aortic annuloplasty. Arch Mal Coeur Vaiss. 1966;59:1305–12.Google Scholar
  45. 45.
    Schneider U, Aicher D, Miura Y, et al. Suture annuloplasty in aortic valve repair. Ann Thorac Surg. 2016;101:783–5.CrossRefGoogle Scholar
  46. 46.
    Lansac E, Di Centa I, Sleilaty G, et al. Remodeling root repair with an external aortic ring annuloplasty. J Thorac Cardiovasc Surg. 2017;153:1033–42.CrossRefGoogle Scholar
  47. 47.
    Izumoto H, Kawazoe K, Kawase T, et al. Subvalvular circular annuloplasty as a component of aortic valve repair. J Heart Valve Dis. 2002;11:383–5.Google Scholar
  48. 48.
    Mukaida M, Kawazoe K, Okabayashi H. Long-term results of aortic valve repair. J JCS Cardiol. 2012;20:65–70.CrossRefGoogle Scholar
  49. 49.
    Kunihara T. Annular management during aortic valve repair: a systematic review. Gen Thorac Cardiovasc Surg. 2016;64:63–71.CrossRefGoogle Scholar
  50. 50.
    Holubec T, Higashigaito K, Belobradek Z, et al. An expansible aortic ring in aortic root remodeling: exact position, pulsatility, effectiveness, and stability in three-dimensional CT study. Ann Thorac Surg. 2017;103:83–90.CrossRefGoogle Scholar
  51. 51.
    Schäfers HJ, Langer F, Glombitza P, et al. Aortic valve reconstruction in myxomatous degeneration of aortic valves: are fenestrations a risk factor for repair failure? J Thorac Cardiovasc Surg. 2010;139:660–4.CrossRefGoogle Scholar
  52. 52.
    Trusler GA, Moses CAF, Kid BSL. Repair of ventricular septal defect with aortic insufficiency. J Thorac Cardiovasc Surg. 1973;66:394–403.Google Scholar
  53. 53.
    Marom G, Haj-Ali R, Rosenfeld M, et al. Aortic root numeric model: correlation between intraoperative effective height and diastolic coaptation. J Thorac Cardiovasc Surg. 2013;145:303–4.CrossRefGoogle Scholar
  54. 54.
    Carpentier A. Cardiac valve surgery: the French correction. J Thorac Cardiovasc Surg. 1983;86:323–37.Google Scholar
  55. 55.
    Langer F, Aicher D, Kissinger A, et al. Aortic valve repair using a differentiated surgical strategy. Circulation. 2004;110:II67–73.CrossRefGoogle Scholar
  56. 56.
    David TE, Armstrong S. Aortic cusp repair with Gore-tex sutures during aortic valve-sparing operations. J Thorac Cardiovasc Surg. 2010;139:1340–2.CrossRefGoogle Scholar
  57. 57.
    David TE, Armstrong S, Ivanov J, Webb GD. Aortic valve sparing operations: an update. Ann Thorac Surg. 1999;67:1840–2.CrossRefGoogle Scholar
  58. 58.
    Kunihara T. Technique of aortic valve repair for aortic regurgitation and preoperative echocardiographic assessment. Jpn J Med Ultrasonics. 2018;45:403–17.CrossRefGoogle Scholar
  59. 59.
    Grinda J-M, Latremouille C, Berrebei AJ, et al. Aortic cusp extension valvuloplasty for rheumatic aortic valve disease: midterm results. Ann Thorac Surg. 2002;74:438–43.CrossRefGoogle Scholar
  60. 60.
    Stephens EH, Hope TA, Kari FA, et al. Greater asymmetric wall shear stress in Sievers’ type 1/LR compared with 0/LAT bicuspid aortic valves after valve-sparing aortic root replacement. J Thorac Cardiovasc Surg. 2015;150:59–68.CrossRefGoogle Scholar
  61. 61.
    Jermihov PN, Jia L, Sacks MS, et al. Effect of geometry on the leaflet stresses in simulated models of congenital bicuspid aortic valves. Cardiovasc Eng Technol. 2011;2:48–56.CrossRefGoogle Scholar
  62. 62.
    Tolan MJ, Daubeney PE, Slavik Z, et al. Aortic valve repair of congenital stenosis with bovine pericardium. Ann Thorac Surg. 1997;63:465–9.CrossRefGoogle Scholar

Copyright information

© The Japan Society of Ultrasonics in Medicine 2018

Authors and Affiliations

  1. 1.Department of Cardiac SurgeryJikei University School of MedicineTokyoJapan

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