Minimally Invasive Valve-Sparing Aortic Root Replacement With Native Commissural Asymmetry

A 69-year-old woman with a body surface area of 1.8 m² presented with progressive dyspnea on exertion (New York Heart Association (NYHA) Class III), severe aortic regurgitation, and an ascending aortic aneurysm measuring 4.4 cm. Preoperative transthoracic echocardiography demonstrated a trileaflet aortic valve with moderate-to-severe central regurgitation, a vena contracta width of 0.5 cm, a pressure half-time of 611 ms, and holodiastolic flow reversal in the descending aorta. Four-dimensional flow cardiac magnetic resonance imaging (MRI) demonstrated a 24 percent aortic regurgitant fraction, mild left ventricular dilatation, and mildly reduced systolic function, with a left ventricular ejection fraction (LVEF) of 44 percent, left ventricular end-diastolic volume index (LVEDVi) of 91 mL/m², and left ventricular end-systolic volume index (LVESVi) of 51 mL/m². Computed tomography (CT) angiography showed the 4.4 cm ascending aneurysm and commissural asymmetry. Using medical software, multiplanar CT reconstruction defined the aortic valve short-axis plane, and angles between adjacent commissures were measured relative to the geometric center (1). The left coronary cusp measured 105°, compared with 127° and 129° for the right and non-coronary cusps, respectively.

The patient underwent minimally invasive elective root replacement and aortic valve repair through a J-type upper hemisternotomy with central aortic and femoral venous cannulation. The ascending aorta was replaced, and the aneurysmal root sinus tissue was resected. Intraoperative inspection demonstrated pliable trileaflet tissue, with geometric heights of 14, 17, and 15 mm for the right, left, and non-coronary cusps, respectively. The El-Khoury height was 26 mm, and the annulus was sized over a 24 mm Hegar dilator. Given the favorable leaflet quality and coaptation potential, native valve preservation was favored. A 24 mm root graft was selected to optimize coaptation with the small right coronary cusp. Consistent with the authors’ principles of individualized valve-sparing root reconstruction, the commissures were reimplanted according to their native asymmetric orientation, maintaining a slightly smaller angle at the left cusp rather than reconstructing symmetrically (1-3).

Following reimplantation, the effective heights were 9 mm for the left and non-coronary cusps and 7 mm for the right cusp. Coaptation was excellent without plication. The coronary buttons were reimplanted, the graft-to-graft anastomosis was performed, and the patient was weaned from bypass. Intraoperative transesophageal echocardiography demonstrated no residual aortic regurgitation, with a mean transvalvular gradient of 5 mmHg. Predischarge transthoracic echocardiography demonstrated a mean gradient of 6.7 mmHg, peak velocity of 1.8 m/s, and trace residual aortic insufficiency.

Careful assessment of leaflet quality, coaptation potential, and native commissural geometry can support individualized root reconstruction. Rather than reconstructing a symmetric root, the authors’ strategy deliberately reproduced the native commissural asymmetry. This case demonstrates that small leaflet geometric height alone should not preclude valve-sparing root replacement. Although geometric height has been proposed as an important consideration for patient selection, it should be interpreted in the context of overall valve anatomy and repairability (4). In this case, preservation of native commissural asymmetry combined with tailored graft sizing enabled effective leaflet coaptation despite a small right coronary cusp, resulting in excellent early hemodynamic and echocardiographic outcomes.

References

1. Owolabi G, Chung MM, Nickles J, MacDonald WJ, Elmously A, Takayama H. How to manage residual aortic regurgitation after an aortic valve-sparing operation: Practical tips. JTCVS Struct Endovasc. 2026 Feb 16;10:100103.
2. Rajesh K, Chung MM, Levine D, et al. Importance of surgeon’s experience in practicing valve-sparing aortic root replacement. JTCVS Open. 2024;21:19-34.
3. Singh SK, Levine D, Patel P, et al. Reintervention after valve-sparing aortic root replacement: a comprehensive analysis of 781 David V procedures. J Thorac Cardiovasc Surg. 2024;167(4):1229-1238.e7.
4. Yamanaka S, Takanashi S, Shimokawa T, Kunihara T. Exploratory study of the measurement of geometric height in 3D transesophageal echocardiography as a predictor of valve-sparing root replacement for aortic regurgitation. J Clin Med. 2024;13(24):7712.

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