Aortic Leaflet BillowingClare Ridley, MD

Assistant Professor, Cardiothoracic AnesthesiologyWashington University in St. Louis

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Overview

Define billowingEffects of billowingRelevance Video illustrations (TEE) in OR pre/post repair

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Billowing: Definition

Nadir of the cusp below the ventriculo-aortic junction (VAJ)Leaflet tip is above the annular plane (vs.

prolapse)Symmetrical or asymmetrical billowing

le Polain de Waroux (JACC Imaging, 2009)

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Billowing versus Prolapse

Billowing and prolapse• Two ends of a spectrum of valvular

incompetency

Billowing over time may become prolapse• Prolapse:

– Cusp free margin lower than adjacent cusps

– Below the normal aortic valve coaptation level (de Kerchove ATS 2009)

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Spectrum: Billowing to Prolapse

NORMAL BILLOWING PROLAPSE

Flachskampf, Eur J of Echo 2010

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Billowing: Coaptation Length Effects

le Polain de Waroux (JACC Imaging, 2009)

(a) Aortic annulus (dashed line)(g) Degree of billowing (distance from VAJ to cusp nadir)(h) Distance from VAJ to cusp tip(Relative level of cusp coaptation)(i) Coaptation length

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Billowing: Relevance

Retrospective review of 186 consecutive patients getting AV repair for AIMedian follow up: 18 months

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Billowing: Relevance

AR 3+ or greater associated with: (univariate)• Coaptation length• Degree of cusp billowing• Coaptation below VAJ• Larger diameter of the VAJ and STJ• Residual AR• Width of its vena contracta

No numerical value for billowing length given

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Billowing: Relevance

AR 3+ or greater (multivariate analysis):• Coaptation length• Coaptation below VAJ• Larger diameter of the VAJ and STJ• Residual AR

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Billowing: Relevance

Retrospective review of 86 patientsAortic root replacement +/- cusp repairMedian follow up 46.4 monthsLooked at:

• Effective height (VAJ to central free margin of cusp)• Geometric height (VAJ to edge of body of Arantius)• Root dimensions

Billowing seen in 30.2% of patients

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Billowing: Relevance

AR >mild associated with:• Lower eH (7.47+/-3.3mm vs 8.81+/-2.1mm (p+0.049)• Postop eccentric jet• Cusp billowing (78.6% in >mild AR group vs 20.8%

in ≤mild AR group (p<0.0001)

No significant difference in eH in patients with and without cusp billowing (8.36 ± 2.9 mm versus 8.69 ± 2.1 mm; p = 0.55)

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Billowing: Relevance

Univariate analysis for reoperation:• Larger preop STJ (p = 0.046)• Aortic dissection (p = 0.0049)• Billowing cusp (p = 0.0050)• Postoperative eccentric jet (p = 0.042)

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Patient 1

49 y/o man with a BAV, severe AR, Bicuspid LVEDD-6.9cm. Aortic Valve Repair (El-Koury Technique)

Primary Leaflet Repair and Annular (and Subannular) Reduction with Raphé Release Annulus diameter reduction of 26 to 23mm 8-10mm coaptation zonePeak / mean gradient=35/18 mmHg.No AR post CPB. Moderate AR 25 months later.

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Patient 1

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Patient 1 Patient 1: PRE AV Repair

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Patient 1

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Patient 1 POST AV Repair

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Patient 1 POST AV Repair

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Patient 1

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Patient 1

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Patient 1 POST OP FOLLOW UP TTE (2 years later)

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Patient 1 POST OP FOLLOW UP TTE (2 years later)

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Patient 1

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Patient 229 y/o man with severe, symptomatic AR

and a BAV

Aortic Valve Repair with Direct Leaflet Repair (El-Khoury Technique) with Sub-Commissural Annuloplasty

Annulus diameter reduction of 27mm to 24mm

Coaptation zone 7.3mm

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Patient 2Postop peak / mean AV gradient

25/14mmHg.

Post CPB: Trace AR

6 month follow up: Moderate AR (holodiastolic flow reversal in upper DTA)

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Patient 2 Patient 2: PRE AV Repair

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Patient 2 Patient 2: POST AV Repair

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Patient 2 Patient 2: POST AV Repair

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Patient 2 Patient 2: POST AV Repair

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Patient 2

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Patient 2

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3D Modeling of the Aortic Valve (M. Labrosse, B. Sohmer)

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3D Modeling of the Aortic Valve (M. Labrosse, B. Sohmer)

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3D Modeling of the Aortic Valve

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Future Areas of Research

3D modeling

Interaction between Sievers anatomy and billowing? (Do type I repairs have more AI?)

Does symmetry of billowing affect outcome?

Is Billowing associated with type of surgical repair? • SCA vs Reimplantation vs Remodeling

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Summary: Concepts

Billowing is different from prolapse

Associated with moderate or severe AR on follow up

May increase risk of reoperation

More studies are needed to define how billowing affects the coaptation zone

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Thank You

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References Augoustides, JGA, et al. Advances in aortic valve repair: Focus on functional

approach, clinical outcomes, and central role of echocardiography. JCVA2010; 24(6):1016–1020.

De Kerchove, L, et al. Cusp prolapse repair in trileaflet aortic valves: Free margin plication and free margin resuspension techniques. ATS 2009; 88(2):455–461.

Flachskampf, FA, et al. Recommendations for transoesophagealvechocardiography: update 2010. Eur J of Echo 2010; 11: 557–576.

Labrosse, MR, et al. Modeling leaflet correction techniques in aortic valve repair: A finite element study. J of Biomechanics 2011; 44:2292–2298.

Le Polain de Waroux, JB, et al. Mechanisms of recurrent aortic regurgitation after aortic valve repair. JACC: Cardiovascular Imaging 2009; 2(8): 931-939.

Miyahara S, et al. Impact of postoperative cusp configuration on mid-term durability after aortic root reimplantation. J of Heart Valve Dis 2013;22:509-516.

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References Shafers HJ, et al.. Preservation of the bicuspid aortic valve. Ann Thorac Surg

2007; 83:S740-5.

Sievers, H, et al. A classification system for the bicuspid aortic valve from 304 surgical specimens. J Thorac Cardiovasc Surg 2007;133:1226-33.

Van Dyck M, et al. Complications after aortic valve repair and valve-sparing procedures. Ann Cardiothorac Surg 2013;2(1):130-139.

Van Dyck M, et al. Transesophageal echocardiographic evaluation during aortic valve repair surgery. Anesth Analg 2010; 111(1):59-70.

Zoghbi WA, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003;16:777-802.