Intraoperative Transesophageal Echocardiographic Predictors of Recurrent Aortic Regurgitation after Aortic Valve Repair

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Intraoperative Transesophageal Echocardiographic
Predictors of Recurrent Aortic Regurgitation
after Aortic Valve Repair
le Polain JB, Pouleur AC, Vancraeynest D, Pasquet
A, Gerber B, Vandijck M, Noirhomme P, El Khoury
G, Vanoverschelde JL
Cliniques Universitaires Saint Luc, Brussels,
Belgium Université Catholique de Louvain
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Aim of the study

• The present study examines the intraoperative
  echocardiographic features associated with "late
  failure" of aortic valve repair.

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Method Study population

• From 12/1995 to 06/2007
• 186 consecutive patients (51 women, mean age
  54-Yrs)
• - Aortic valve repair for significant AR
• - With comprehensive pre-, intra- and follow-up
  echocardiography
• 122 pts (group A, 53- Yrs) with no AR
• 23 pts (group B, 50- Yrs) with gt grade 1 AR
• 41 pts (group C, 63- Yrs) with
  recurrent severe AR
• Compared for immediate post-operative TEE
  measurements.
• Analysis of the cause of recurrence (group B
  C).

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Method TEE analysis

• Pre-operative and immediate postoperative TEE

• Annulus
• Sinuses
• ST junction
• Tubular aorta

120 degree -LAX

• Height of the sinuses
• Coaptation length
• Symmetry of the coaptation
• Tips to annulus
• Cusps belly to annulus

• Eccentric Jet
• Vena contracta wide

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Results (1) Follow-up

• Mean Follow-up 24 months
• 41 pts had recurrent severe AR
• 23 needed a REDO
• F-up TEE identified the cause of repair failure
  as
• Cusp prolapse 26 pts
• Restrictive cusp motion 9 pts
• Rupture of a pericardial patch 3 pts
• Aortic dissection 2 pts
• Endocarditis 1 pt

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Results (2) Pre-operative characteristics
Before surgery Group A (n112) Group B (n23) Group C (n41) P value
Bicuspid () 40 17 37 0.12
Marfan () 0 9 15 lt0.001
Restrictive AR () 13 43 46 lt0.001
Annulus (mm) 25 4 24 4 26 6 0.27
Sinus (mm) 40 8 39 9 41 13 0.61
ST jct (mm) 35 9 35 9 34 9 0.93
Tubular Ao (mm) 42 11 39 8 37 13 0.14
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Results (3) immediate post-op TEE
After surgery Group A (n112) Group B (n23) Group C (n41) P value
Coapt. Length (mm) 6.6 2.8 3.2 1.4 2.2 1.6 lt0.001
Tips - annulus (mm) 6.9 4.3 3.0 3.1 0.1 4.2 lt0.001
Cusp - annulus (mm) -1.2 2.8 -1.5 3.2 - 3.9 4.8 lt0.001
Vena contracta (mm) 0.1 1.1 2.4 1.7 2.6 1.4 lt0.001
Eccentric Jet () 9 30 73 lt0.001
Annulus (mm) 21 4 21 4 26 4 lt0.001
Sinus (mm) 29 5 30 5 31 5 0.04
ST jct (mm) 26 4 24 4 27 4 lt0.01
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Results (4) Cox univariate analysis
Preoperative Type 3 AR Marfan disease Postoperat
ive The coaptation length The degree of cusp
billowing The level of coaptation (relative to
the annulus) The diameter of the aortic
annulus The diameter sino-tubular junction The
presence of a residual AR The severity of
residual AR (vena contracta width) Were found
to correlates with AR failure
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Results (4) Cox multivariate analysis
Independent predictors of late AR recurrence
Multivariate analysis HR IC 95 exp ß P value
Coapt. Length 0.82 0.63 1.00 0.05
Tips below the annulus 7.90 6.52 - 9.28 lt0.01
Residual AR 5.30 1.47 - 6.57 0.01
Aortic annulus 1.18 1.03 - 2.45 0.01
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TEE decision chart
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4-years Survival free from redo according to TEE
Log rank p lt 0.001
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Example pre and immediate post operative TEE of
patient with late failure
Pre-op TEE Post-op TEE
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Conclusion

• Our results demonstrate that intraoperative TEE
  can be used to identify pts undergoing AR repair
  who are at increased risk for late repair failure