Discussion

AVr is an attractive option to treat patients with pure AR. There are a number of recognised benefits associated with preserving the native aortic valve and avoiding prosthesis-related complications such as thrombosis, endocarditis, bioprosthetic degeneration, mechanical valve dysfunction and haemorrhagic events associated with the life-long anticoagulation treatment. Despite these advantages, however, the long-term benefits of AVr procedures remain to be fully defined. One of the main concerns is related to the durability of the repair, that is, freedom from recurrence of significant AR and the need for a re-operation.2

A recent systematic review compared outcomes of AVr and replacement in patients with aortic regurgitation. In-hospital mortality was 1.3% for the repair and 3.6% for the replacement and 1-year mortality was 3.6% and 8.8%, respectively. Of note however, the re-operation rate at 1 year was higher for AVr (8.8% vs 3.7%).3 Successful long-term outcomes with AVr procedures have been reported by high volume centres and mainly driven by experience with the surgical techniques and the patient selection. Consequently, AVr procedures are currently recommended by the European Society of Cardiology (ESC)/European Aossociation of Cardiothoracic Surgery (EACTS) guidelines in selected patients performed in specialised aortic centres. Valve repair or VSRR surgery should be considered in patients with pliable non-calcified tricuspid or bicuspid valves who have a type I (enlargement of the aortic root with normal cusp motion) or type II (cusp prolapse) mechanism of aortic regurgitation. Reimplantation or remodelling with aortic annuloplasty is a Class Ic recommendation in young patients with aortic root dilation and tricuspid aortic valves, when performed by experienced surgeons.4

David et al5 published the long-term outcomes of 296 consecutive VSRR: survival at 5, 10 and 15 years was 95%, 93% and 76.5%, respectively; freedom from moderate or severe aortic regurgitation at 5, 10 and 15 years was 98%, 93% and 89%, respectively, and just three patients required a re-operation on the aortic valve. Excellent results have also been reported by the most experienced European centres. El Khoury's group reported 85% freedom from re-operation at 10 years after AVr.6 Data from the AVIATOR Registry demonstrate a freedom from re-operation at 7 years of 90.5% for aortic root aneurysms, 100% for tubular aortic aneurysm and 97.5% for isolated AR.7 A multicentre (four units) German experience with 1015 VSSR procedures showed 90% freedom from aortic valve replacement at 8 years.8 A subanalysis performed in 764 patients with echocardiographic follow-up found that one-third of patients left the operating room with some residual AR. Furthermore, 13% of patients without postoperative AR presented with new and significant AR within the first 5 years and that progression of AR was detected in 30% of patients who had left the hospital with mild residual AR. The progression of AR remained stable in 4% of the patients and lead to re-operation in 26%. The main risk factor for new-onset AR was additional cusp repair, while risk factors for mild residual AR were greater aneurysm size and preoperative aortic regurgitation severity.9 The Belgian group led by El Khoury also highlight the crucial importance of the TOE in assessing the repair and identified three risk factors for early failure: residual AR, particularly eccentric jet; cusp coaptation below the aortic annulus and a coaptation length <4 mm.10,6,7,8,9

We presented our UK experience with AVr procedures and our results appear to be in line with the early experience reported from the European aortic centres. We report excellent immediate and early surgical results: no in-hospital mortality, low incidence of complications and short postoperative stay. Over 82% of the patients left the operating theatre with no or trivial AR, 13% with a mild central AR and just three patients with a mild eccentric AR. Despite the good early surgical results, however, echocardiographic follow-up showed a less satisfactory durability of the repair, with 18% of patients having moderate AR and 4% with severe AR. All patients were alive at 5.08±2.29 years clinical follow-up, and the freedom from re-operation at 8 years was 88.15%±1.51%.

One patient required a re-operation 6 years after VSRR. With the benefit of hindsight, we should have been more aggressive in stabilising the aortic annulus of this patient referred late to surgery and consequently had severe annular and left ventricular dilatation. Reports from experienced centres show that suture annuloplasty with polytetrafluoroethylene or ring/band implant is probably associated with better long-term freedom from recurrence of AR when the aortic annulus is severely dilated.5 11–13

As clearly stated in the international guidelines, the choice of the surgical procedure in patients with pure AR should be adapted to patho-anatomical factors (the presence of an aortic root aneurysm and characteristics of the cusps), the experience of the surgical team and the patient’s choice (life expectancy and desired anticoagulation status).4

No follow-up data are available regarding the current practice in the UK. The most recent available data on VSRR from NICOR (National Institute for Cardiovascular Outcomes Research) reported 103 procedures performed over a period of 3 years across the country (average of 33 cases/year).14 This suggest that VSRR remains an underperformed procedure in current UK practice. The situation in the USA is similar when we consider that the STS Database recorded that out of 13 743 root surgical procedures performed between 2004 and 2010, only 14% were VSRR procedures, only 82 centres performed VSRR procedures, with only 5% of centres performing more than 16 cases/year and only 2 centres 100 VSRRs/year.15