Surgical outcomes of aortic valve repair for specific aortic valve cusp characteristics; retraction, calcification, and fenestration

Objectives: We investigated the predictive value of aortic valve cusp retraction, calcification, and fenestration for aortic valvuloplasty feasibility. Methods: Multicenter data were collected for 2082 patients who underwent surgical aortic valvuloplasty or aortic valve replacement. The study population had retraction, calcification, or fenestration in at least one aortic valve cusp. Controls had normal or prolapsed cusps. Results: All cusp characteristics demonstrated significantly increased odds ratios [ORs] for switch to valve replacement. This effect was strongest for cusp retraction, followed by calcification and fenestration (OR, 25.14; P ≤ .001; OR, 13.50, P ≤ .001; OR, 12.32, P ≤ .001). Calcification and retraction displayed increased odds for developing grade 4 aortic regurgitation compared with grade 0 or 1 combined on average over time (OR, 6.67; P ≤ .001; OR, 4.13; P = .038). Patients with cusp retraction showed increased risk for reintervention at 1- and 2-year follow-up after aortic valvuloplasty (hazard ratio, 5.66; P ≤ .001; hazard ratio, 3.22, P = .007). Cusp fenestration was the only group showing neither an increased risk of postoperative severe aortic regurgitation (P = .57) or early reintervention (P = .88) compared with the control group. Conclusions: Aortic valve cusp retraction, calcification, and fenestration were all related to increased rates of switch to valve replacement. Calcification and retraction were associated with recurrence of severe aortic regurgitation. Retraction was related to early reintervention. Fenestration was neither associated with recurrence of severe aortic regurgitation or reintervention. This indicates that surgeons are well able to distinguish aortic valve repair candidates in patients with cusp fenestration.