Commentary: Rooting around dilated left ventricles has implications for the fate of aortic valves

Central MessagePreserving the aortic valve when doing root interventions is a worthy goal and achievable. Durability of the repair decreases with increasing LV size and the need for cusp interventions.That what cannot be repaired is not to be regretted.—Samuel JohnsonSee Article page 1069. Preserving the aortic valve when doing root interventions is a worthy goal and achievable. Durability of the repair decreases with increasing LV size and the need for cusp interventions. See Article page 1069. Guo and colleagues1Guo M.H. Cole E. Fei L.Y.N. Mussani J. Tran D. Glineur D. et al.Preoperative left ventricular end-systolic dimension predicts occurrence of aortic insufficiency following aortic valve-preservation and repair surgery.J Thorac Cardiovasc Surg. 2022; 164: 1069-1076.e2Abstract Full Text Full Text PDF Scopus (5) Google Scholar report on the durability of valve sparing root procedures on freedom from aortic insufficiency (AI) and how this varies with left ventricular (LV) dilatation. Using a best-fit model, LV end-systolic diameter index (LVESDi) was found to predict occurrence of AI better than LVESD, LV end-diastolic diameter, or LV end-diastolic diameter index. Occurrence of >1+ AI at 6 years was low (7.8%) in those with small ventricles (LVESDi ≤1.4 cm/m2), worse (19.1%) in those with LVESDi 1.5 to 1.9 cm/m2, and further worse (49.7%) in the group with large ventricles (LVESDi ≥2.0 cm/m2). The all-inclusive study did not examine recurrence of AI per se, because one-third of patients had trivial or no AI before surgery. However, in the subset of patients with preoperative AI, recurrence of >1+ AI at 6 years was 55.0% in the group with LVESDi ≥2.0 cm/m2 and 23.7% in those with LVESDi <2.0 cm/m2. The study relied on retrospective reports of echocardiographic examinations that are susceptible to errors that might otherwise be circumvented through use of a core lab. The study should be taken in this context, but this does not significantly diminish the results. Guo and colleagues1Guo M.H. Cole E. Fei L.Y.N. Mussani J. Tran D. Glineur D. et al.Preoperative left ventricular end-systolic dimension predicts occurrence of aortic insufficiency following aortic valve-preservation and repair surgery.J Thorac Cardiovasc Surg. 2022; 164: 1069-1076.e2Abstract Full Text Full Text PDF Scopus (5) Google Scholar offer some predictive power regarding the fate of the aortic valve that we can use to guide our approaches. If there is no significant AI preoperatively and the LV is not dilated, then the durability of the aortic valve is highly likely. But if there is significant preoperative AI and the LV is dilated, there is significant probability that AI will recur. There was indication on univariate analysis that the number of cusps repaired and shaving of the valve correlated to fallibility of the repair. Leaving the operating room with residual 1+ AI was found to predict fallibility on multivariable analysis (risk adjusted odds ratio, 5.77), but 6 (22%) of 27 patients with intraoperative residual 1+ AI had no progression of AI. These findings suggest improvement of AI over time or resilience of the valve should not to be expected routinely and minor flaws are incompletely forgiving. Is it better to leave someone with his or her own valve that is mildly incompetent or to replace the valve once it is apparent that residual AI is the best repair that can be achieved? Many factors will go into this decision, including the choice of prosthesis in the event repair is abandoned. We are moving closer to personalized medicine and tailoring care to a specific person. Guo and colleagues1Guo M.H. Cole E. Fei L.Y.N. Mussani J. Tran D. Glineur D. et al.Preoperative left ventricular end-systolic dimension predicts occurrence of aortic insufficiency following aortic valve-preservation and repair surgery.J Thorac Cardiovasc Surg. 2022; 164: 1069-1076.e2Abstract Full Text Full Text PDF Scopus (5) Google Scholar remind us that the way we achieve this is by measuring outcomes of interventions with granularity so that findings can be applied with greater precision to the person who stands before us. Preoperative left ventricular end-systolic dimension predicts occurrence of aortic insufficiency following aortic valve preservation and repair surgeryThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 4PreviewPreoperative left ventricular (LV) end-systolic dimension (LVESD) ≥5.0 cm is a class IIa indication for surgical intervention for aortic insufficiency (AI); however, the effect of LV dilatation on the longevity of the aortic valve (AV) has not yet been investigated. This study aimed to assess the impact of preoperative LV dimension on the long-term outcome of AV preservation surgery. Full-Text PDF