Aortic Valve Repair for Leaflet Prolapse Joel Price, MD, MPH, Laurent De Kerchove, MD, and Gebrine El Khoury, MD In the setting of aortic regurgitation caused by leaflet prolapse, aortic valve replacement has traditionally been the recommended treatment. However, the ad- vent of effective and durable leaflet repair techniques has enabled the repair of the regurgitant aortic valve. As for the mitral valve, repair has the potential to reduce the incidence of prosthesis-related complica- tions including endocarditis, thromboembolism, an- ticoagulant-related hemorrhage, and reoperation. In this article, we describe our systematic approach to the assessment and repair of aortic leaflet prolapse. PATHOLOGY Aortic insufficiency can result from either leaflet dysfunction or dilation of any component of the functional aortic annulus (FAA), which consists of the sinuses of Valsalva, the aortoventricular junction, and the sinotubular junction. We have previously described a mechanistic classification for causes of aortic insufficiency. 1,2 Leaflet dysfunction can be de- scribed as type 2 (leaflet prolapse) or type 3 (leaflet restriction). Type 2 dysfunction is the more common mechanism and will be the focus of the current arti- cle. In general, leaflet prolapse is the result of a rela- tive excess in the length of the free margin. Although leaflet prolapse can exist in isolation, it is more commonly associated dilation with one or many components of the FAA. For the trileaflet valve, prolapse of the right or noncoronary cusps is significantly more common than left coronary cusp prolapse. In younger patients, prolapse is often asso- ciated with root dilatation and connective tissue dis- order. Leaflet prolapse is more common in bicuspid valves. 3 In the bicuspid valve, prolapse of the ante- rior leaflet is significantly more common than poste- rior leaflet prolapse. These patients are frequently young and have associated aortic root dilation. The decision to perform FAA annuloplasty depends on annular dimensions and tissue quality. If necessary, a reimplantation aortic valve-sparing root replace- ment is most commonly performed. This procedure has the potential to alter the geometry of the aortic root and can exacerbate existing leaflet prolapse. As such, if an FAA annuloplasty is to be performed, reassessment and correction of leaflet prolapse are usually performed afterward. The focus of this article will be the reconstruction of leaflet prolapse in tri- cuspid valves. However, the same techniques can be applied to the true bicuspid or Sievers type 0 bicus- pid valve. 4 The repair type 1 or raphed bicuspid valve is more complex because of the management of the raphe and pseudocommissure. In these valves, leaflet dysfunction is often restrictive, and more in- volved reconstructive techniques are required. Department of Cardiovascular and Thoracic Surgery, Cli- niques Universitaires Saint-Luc, Univérsite Catholique de Louvain, Brussels, Belgium. Dr. De Kerchove reports receiving consulting fees from Ethicon and lecture fees from Edwards Lifesciences and Cryolife. Dr. Price and Dr. El Khoury have no commercial interests to disclose. Address reprint requests to Gebrine El Khoury, MD, Clin- iques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium. E-mail: Elkhoury@chir.ucl.ac.be Figure 1. Aortic valve exposure for assessment and repair. (Color version of figure is available online at http://www.semthorcardiovascsurg.com.) Figure 2. Placement of the reference suture. (Color version of figure is available online at http://www. semthorcardiovascsurg.com.) TECHNIQUES MY WAY 149 1043-0679/$-see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1053/j.semtcvs.2011.08.010