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Repair of aortic valve cusp prolapse
Munir Boodhwani
*, Laurent de Kerchove
, David Glineur
, Phillipe Noirhomme
, Gebrine El

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
Department of Cardiovascular and Thoracic Surgery Cliniques Universitaires Saint-Luc,
Avenue Hippocrate 10, 1200 Brussels, Belgium
Aortic valve preservation and repair is emerging as a feasible and attractive alternative to
aortic valve replacement in young patients with aortic valve insufficiency. Cusp pathology
requiring repair is present in up to 50% of patients undergoing aortic valve repair or valve
preserving surgery and may occur in isolation or in conjunction with ascending aortic
disease. Diagnosis of cusp prolapse can usually be made on preoperative
echocardiography and is confirmed on surgical inspection. Techniques available for the
correction of cusp prolapse in a trileaflet aortic valve include free margin plication, and free-
margin resuspension. These techniques can be used alone or in combination and both
provide stable midterm results. Choice of technique may, therefore, be tailored to the cusp
pathology encountered.
Keywords: Aortic valve; Cusp repair; Surgical technique; Valve repair; Valve sparing

Although valve preserving root replacement surgery,
using the reimplantation w1x or remodeling w2x
techniques, is increasingly being used to treat aortic
root disease, techniques for aortic valve repair for
isolated aortic insufficiency (AI) are applied
heterogeneously and infrequently. A major limitation
to the more generalized application of aortic valve
repair techniques is the absence of a common
framework for valve assessment which can help to
guide the approach to valve repair. Over the past
decade, inspired by other classifications w3, 4x, we
have developed a classification for AI which
encompasses all types of AI, provides a common
language for communication across

* Corresponding author. Dr. Munir Boodhwani, Service de Chirurgie
Cardiovasculaire et Thoracique, Cliniques Universitaires Saint-Luc
UCL 90, Avenue Hippocrate 10, 1200 Brussels, Belgium.
Tel.: q32-2-764-6106; fax: q32-2-764-8960.
2009 European Association for Cardio-thoracic Surgery
different disciplines, guides the repair techniques
employed, and can help to predict mid-term outcome
w5x (Schematic 1).
Type I lesions, as in Carpentiers classification of
mitral valve regurgitation, are associated with normal
leaflet motion. This is largely due to lesions of the
functional aortic annulus with type Ia AI due to sino-
tubular junction enlargement and dilatation of the
ascending aorta, type Ib due to dilatation of the
sinuses of Valsalva and the sino-tubular junction, type
Ic due to dilatation of the ventriculo-aortic junction,
and lastly type 1d due to cusp perforation without a
primary functional aortic annulus lesion. Type II AI is
due to cusp prolapse secondary to excessive cusp
M. Boodhwani et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2008.003806
tissue or due to commissural disruption. Type III AI is
due to leaflet restriction which may be found in
bicuspid, degenerative, or rheumatic valvular disease
due to calcification, thickening, and fibrosis of the
aortic valve leaflets. Repair of cusp prolapse (type II
dysfunction), thus, is one component of a larger

Schematic 1. Repair-oriented functional classification of aortic
insufficiency with a description of disease mechanisms and repair
techniques employed. (STJ, sino-tubular junction; SCA,
subcommissural annuloplasty). Multiple mechanisms of
insufficiency may be present in one valve. In particular, patients
with type Ia (ascending aortic dilatation) and type Ib (aortic root
dilatation) should be examined for the presence of cusp prolapse
(type II). Adapted from ref. w5x.
work of aortic valve repair techniques that need to be
applied in a systematic manner in order to achieve a
durable outcome. It is important to note that patients
may present with multiple lesions contributing to their
AI. In particular, patients with dilatation of the
supracoronary ascending aorta (type Ia) and aortic
root dilatation (type Ib) may present with concomitant
cusp prolapse (type II) which should be carefully
Definition and echocardiographic diagnosis of
cusp prolapse
Normal aortic valve cusp coaptation occurs
approximately at a level corresponding to the middle
of the sinuses of Valsalva, i.e. halfway between the
ventriculo-aortic junction and the sinotubular junction.
Cusp prolapse, therefore, is strictly defined as the
motion of the cusp free margin below this level. In the
setting of a trileaflet aortic valve and single cusp
prolapse, the prolapse can be appreciated relative to
the other normal cusps, or may be defined, in an
absolute manner, as the free margin of the cusp is
observed below the physiologic coaptation level.
Occasionally, symmetric prolapse of multiple cusps
may be present, typically after a valve sparing root
replacement procedure. In this scenario, all three
cusps may coapt below the physiologic coaptation
level without the presence of significant AI. Despite
the absence of AI in this setting, cusp repair with the
objective of restoring normal coaptation is critical for
the long-term function of the valve.
Cusp prolapse can usually be detected
echocardiographically but requires confirmation and
quantification during surgical inspection.
Echocardiographic features of cusp prolapse include
the presence of an eccentric AI jet in the opposite
direction of the prolapsing cusp, visualization of the
valve cusp below the level of the aortic annulus during
diastole, and a diminished length of aortic leaflet
coaptation. These features can be appreciated during
transesophageal echocardiography on the mid-
esophageal long axis view of the aortic valve.
Furthermore, a transverse fibrous band may be
observed on the prolapsing cusp, both on long axis
and short axis views, which helps to confirm the
diagnosis and localize the prolapsing cusp (Video 1).
Surgical assessment of the aortic valve is critical for
the diagnosis and quantification of cusp prolapse and
is discussed below.
Quantification of AI on echocardiography using jet
area can be challenging in the setting of an eccentric
AI jet, because these wall-hugging jets can flatten out
against the wall of the left ventricle. Thus, jet area
may underestimate the severity of AI. Use of vena
contracta and flow convergence methods e.g.
proximal isovelocity surface area (PISA) can help to
quantify the insufficiency but also have some
limitations in the setting of eccentric AI. In patients
with chronic AI, the presence of symptoms and/or
evidence of left ventricular dilatation (LV end diastolic
diameter G70 mm or LV end systolic diameter G50
mm) or reduction in LV function are indications for
surgical intervention.
Surgical techniques
A median sternotomy is performed with cannulation of
the distal ascending aorta and right atrium in patients
with isolated lesions of the aortic valve and/ or root.
The aorta is cross-clamped, and a left ventricular vent
is inserted via the right superior pulmonary vein.
Antegrade, normothermic blood cardioplegia is
administered either through the aortic root or directly
through the coronary ostia in the case of moderate-
severe AI.
M. Boodhwani et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2008.003806

Video 1. Echocardiographic features of aortic insufficiency due to
cusp prolapse on transesophageal (A) long axis, and (B) short axis
views. (This video is looping 5 times).
Valve exposure
A transverse aortotomy is performed 1 cm above the
sinotubular junction starting above the non-coronary
sinus and the posterior 23 cm of aortic wall is left
intact (Video 2). The distal aorta is retracted cephalad.
Full thickness 4-0 polypropylene traction sutures are
placed at the three commisures. An additional
retraction suture may be placed to facilitate exposure
Valve assessment
Axial traction is applied (perpendicular to the level of
the annular plane) on the commissural traction
sutures. This maneuver demonstrates physiological
aortic valve closure position and the area and height
of coaptation can be observed. A prolapsing cusp will
exhibit a transverse fibrous band at this time. The
center of the cusp free margin can then be held with a
forceps and gently pushed down into the left ventricle.
A non-prolapsing cusp will remain at its physiologic
coaptation level (halfway between the base of the
cusp and the commissure), whereas a prolapsing
cusp will be able to be pushed lower due to the
presence of excessive cusp tissue (Video 4).
Reference cusps
A 7-0 polypropylene suture is passed through the
center (nodule of Arantis) of the two non-prolapsing
cusps which serve as a reference. This maneuver

Video 2. Transverse aortotomy and retraction of the distal aorta.

Video 3. Aortic valve exposure using commissural retraction

Video 4. Surgical inspection and analysis of the valve reveals
prolapse of the right coronary cusp, whereas the left coronary and
non-coronary cusps appear to be normal.

Video 5. Non-prolapsing cusps are retracted and used as a
reference to determine optimal free margin length and height of
helps to define the desired height and free margin
length that needs to be achieved on the prolapsing
cusp (Video 5).
Free margin plication
The quantification of excess free margin for the free
margin plication procedure has been previously
described w6x. Gentle traction is applied on the
reference cusp suture keeping the free margin of the
prolapsing cusp parallel with that of the reference
cusp. The prolapsing cusp is gently pulled in the
direction of the reference cusp and a 6-0
polypropylene suture is passed through the
prolapsing cusp at the point at which it meets the
center of the reference cusp going from the aortic to
the ventricular side. Next, the direction of the traction
is reversed and the same suture is passed from the
ventricular to the aortic side of the cusp at the point
M. Boodhwani et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2008.003806
where it meets the middle of the reference cusp. The
length of the cusp free margin between the two ends
of this 6-0 suture represents the excess cusp tissue
which is then plicated by tying the suture ensuring
that the excess tissue remains on the aortic side
(Video 6).
Lastly, the plication is extended by about 510 mm
onto the body of the aortic cusp by adding interrupted
or running locked 6-0 polypropylene sutures (Video 7).
If a large amount of tissue is being excluded as part of
the plication, it may be shaved off using a scalpel or
scissors in order to prevent any impingement of cusp
Free margin resuspension
Excess length of the cusp free margin may also be
corrected using resuspension with
polytetrafluoroethylene (PTFE) suture. This technique
may be used in isolation or in combination with other
cusp repair techniques and is particularly useful in the
setting of a fragile free margin with multiple
fenestrations or to homogenize the free margin when
a pericardial patch is used for cusp augmentation.
This technique is depicted in Video 8.
As shown above in Video 5, a 7-0 polypropylene
suture is first passed through the center (nodule of
Arantis) of the two non-prolapsing cusps which serve
as a reference. A 7-0 PTFE suture is passed twice at
the top of the commissure. Next, one arm of the
suture is passed over and over the length of the free
margin in a running fashion (Video 8). The suture is
locked at the other commissure. A second 7-0 PTFE
is then passed in the same manner along the cusp
free margin (Video 9). The length of the free margin is
reduced by applying gentle traction on each branch of
the PTFE sutures and applying opposite resistance
with a forceps at the middle of the free margin. This
maneuver is used to plicate and shorten the free
margin until it reaches the same length as the
adjacent reference cusp free margin. The same
maneuver is applied for the second half of the free
margin. This

Video 6. Determination of excess cusp tissue and exclusion using
free margin plication.

Video 7. Extension of the cusp plication onto the cusp body.

Video 8. Free margin resuspension is performed using a 7-0 PTFE
suture passed over and over along the cusp free margin.

Video 9. A second PTFE suture is placed in the same manner as
the first and the free margin is shortened to the desired length.
two-step technique for free margin resuspension
allows symmetric and homogeneous shortening.
When the appropriate amount of free margin
shortening is achieved, the two suture ends at each
commissure are tied.
Functional aortic annulus
In addition to repair of cusp prolapse, it is important to
stabilize the functional aortic annulus, which consists
of the ventriculo-aortic junction and the sinotubular
junction. In patients with associated dilatation of the
aortic root, this is performed by root replacement
using a re-implantation technique. In patients with
isolated cusp prolapse or with associated dilatation of
the supra-coronary ascending aorta, subcommissural
annuloplasty sutures are added to stabilize the
proximal portion of the functional aortic annulus.
M. Boodhwani et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2008.003806
Pledgeted 2-0 braided sutures are used (Videos 10
and 11). The first arm of the suture is passed from the
aortic to the ventricular side, in the interleaflet triangle,
and comes back out to the aortic side at the same
level. The second arm of the suture is passed in a
similar fashion just below the first. A free pledget is
added and the suture is tied. This maneuver helps to
stabilize the ventriculo-aortic junction, reduces the
width of the interleaflet triangles and increases the
coaptation surface of the valve leaflets.
Subcommissural annuloplasty is typically performed
at midcommissural height, except at the non-
coronary/right coronary commissure where it should
be performed

Video 10. Subcommissural annuloplasty is performed on the right
coronary/non-coronary commissure.

Video 11. Subcommissural annuloplasty of the non-coronary/left
coronary and the left coronary/right coronary commissures.
higher in order to avoid the membranous septum and
conduction tissue. Care should also be taken in this
area during tying of the suture in order to avoid a tear
in the septum. At the other two commissures, the
subcommissural annuloplasty may be performed at a
lower level if greater increase in the coaptation
surface is desired.
Post-repair echocardiography
Post-repair echocardiography should focus on the
presence of any AI as well as the length and height of
coaptation (Photo 1). An eccentric AI jet, length of
coaptation -5 mm and a level of coaptation below the
mid-height of the sinuses of Valsalva are predictive of
late recurrent AI and should be indications for re-
exploration of the aortic valve w7x.
Among 376 patients having elective aortic valve repair
between 1996 and 2008, 89 (24%) had cusp prolapse
repair in the setting of a trileaflet aortic valve. Free
margin resuspension using PTFE alone was used in
34 (38%) patients, plication alone in 34 (38%) and
PTFEqplication in 21 (24%). Repair of one cusp was
performed in 55 (62%) patients, of two cusps in 18
(20%) and three cusps in 16 (18%). Concomitant
repair techniques included subcommissural
annuloplasty (ns49), supracoronary aortic
replacement (ns11) and valve sparing root
replacement (ns39).

Photo 1. Post-repair transesophageal echocardiographic view of
the aortic valve demonstrating desirable length (green) and height
(red) of coaptation.
There was no hospital mortality. Overall survival at 5
years was 95"5%. Echocardiographic follow-up was
obtained in 94% of patients and at a median follow-up
time of 25 months (range 1107 months), recurrent AI
()2q) occurred in six patients; three of them had aortic
valve replacement. Freedom from reoperation at 5
years was 91"8% for free margin resuspension, 100%
for free margin plication and 94"6% for
PTFEqplication with no significant differences
between groups (Ps0.7). Freedom from recurrent AI
()2q) at 3 years was 87"13% for PTFE, 100% for
plication and 89"11% for PTFEqplication (Ps0.6).
These results are consistent with other reported
series by Aicher et al. where freedom from
reoperation at 5 years after free margin plication was
95% w8x. This series, however, included both
tricuspid and bicuspid aortic valves and free margin
resuspension was not used. In the context of valve
sparing root replacement, David et al. w9x performed
free margin plication in 36% and free margin
reinforcement with PTFE in 22% of a total of 220
M. Boodhwani et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2008.003806
patients. This series also included some patients with
bicuspid aortic valves. Overall freedom from
reoperation at 10 years was 95% for the entire cohort
and separate results for those having cusp
intervention were not reported.
Cusp prolapse is a common cause of AI and can be
detected on echocardiography and on surgical
inspection. Free margin plication and free margin
resuspension are both effective techniques for the
correction of cusp prolapse with or without aortic root
pathology. They can be used alone or in combination
with no significant differences in mid-term outcome
between techniques.
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