Two decades of valve-sparing root reimplantation in tricuspid aortic valve: impact of aortic regurgitation and cusp repair

OBJECTIVES: Our goal was to analyse the influence of preoperative aortic regurgitation (AR) on the necessity of cusp repair during valve-sparing reimplantation (VSR). We focused on patients with tricuspid aortic valves (TAV) and evaluated the impact of AR and cusp repair on long-term outcomes. METHODS: From March 1998 to December 2018, a total of 512 consecutive patients underwent VSR at our institution; of these, 303 had a TAV. The mean age was 53 +/- 15 years, and the median follow-up was 6.12 years. The rate and type of cusp repair were analysed based on preoperative AR. Time-to-event analysis was performed, as well as risk of death, reoperation and AR recurrence. RESULTS: Cusp repair was necessary in 168 (55.4%) patients; the rate rose significantly as AR grade increased (P < 0.001). In-hospital mortality was 1% (n = 3). At 5 and 10 years, overall survival was 92 +/- 2% and 75 +/- 5%, respectively. Freedom from valve reoperation was 95 +/- 2% and 90 +/- 3%. Freedom from AR >2+ and AR >1+ at 10 years was 88 +/- 4% and 70.4 +/- 4.6%, respectively. Independent predictors of death included age, New York Heart Association functional class and type-A aortic dissection. Predictors of AR greater than mild included previous cardiac surgery and severe preoperative AR. CONCLUSION: In patients with TAV receiving VSR, the necessity of cusp repair increased with the degree of preoperative AR. Preoperative AR and cusp repair do not impact long-term survival and aortic valve reoperation, but severe preoperative AR and multiple cusp repair increase the risk of recurrent moderate-to-severe AR. Overall, cusp repair seems to attenuate the negative impact of preoperative AR for at least 1 decade in a majority of patients.