Valve-sparing aortic root replacement: Strategies to avoid residual aortic regurgitation.

Objective: The study objective was to identify quantitative criteria to avoid residual aortic valve regurgitation after valve-sparing aortic root replacement.

Methods: Between 2016 and 2023, 738 adult patients were recruited into the German Aortic Root Repair Registry. A total of 562 patients with datasets on aortic root measurements and tricuspid valve treated with reimplantation valve-sparing aortic root replacement were selected. End points were any grade of residual aortic valve regurgitation and postrepair coaptation height. Tested variables included procedural and anatomic characteristics, including length of cusp margins and geometric cusp heights.

Results: The optimal classifier predicting freedom from residual aortic valve regurgitation was cusp coaptation height 8 to 9 mm or more (sensitivity = 0.7-0.8). Annular downsizing alone was not useful to predict residual aortic valve regurgitation ( = .472, 95% area CI, 0.414-0.54). Patients with a mean free margin length of at least 45 mm and a sum of free margin lengths of at least 125 mm were more likely to present coaptation heights of at least 10 mm (R2 0.038,  = .006).

Conclusions: The target coaptation height after valve-sparing aortic root replacement should exceed 8 to 9 mm. Chances of achieving it can be estimated on the basis of a measurement of cusp quantity. If in doubt when inspecting a valve, numerical criteria can help with surgical decision-making in favor of or against a valve-sparing approach.