Abstract
BACKGROUND: Valve-sparing root replacement (VSRR) prevents prosthesis-related complications in aortic root aneurysms but lacks objective feasibility criteria. Cusp prolapse frequently coexists with aortic root aneurysms, but its effect on VSRR outcomes remains unclear. We characterized prolapse mechanisms using three-dimensional (3D) transesophageal echocardiography (TEE) and examined the correlation between imaging features and surgical success as well as midterm outcomes. METHODS: This retrospective cohort study analyzed the data of 203 consecutive patients considered for VSRR. Cusp prolapse was diagnosed and mechanistically classified using quantitative 3D TEE analysis. The intraoperative findings confirmed regurgitation mechanisms. The outcomes compared the native valve preservation rates, postoperative echocardiographic results, mortality, regurgitation recurrence, and reintervention between prolapse and non-prolapse groups over a median 41-month follow-up period. RESULTS: Among the 203 patients (mean age 48.0±13.7 years), 70 (34.5%) exhibited cusp prolapse. The predominant mechanism was disproportionate free margin (FM) elongation (64.3%). Surgical success was significantly lower in the prolapse group than the non-prolapse group (50.0% vs. 86.5%; P<0.001). Among the patients with cusp prolapse, prolapse mechanisms other than FM elongation, compared with FM elongation, were independently associated with unsuccessful VSRR [odds ratio (OR) =12.44; 95% confidence interval (CI): 3.42-45.24; P<0.001]. In addition, a reduced minimum geometric height was also independently associated with unsuccessful VSRR (OR =0.70; 95% CI: 0.50-0.97; P=0.035). There were no significant differences in the midterm outcomes between the prolapse and non-prolapse groups in terms of the echocardiographic parameters (P=0.373), mortality (P=0.581), regurgitation recurrence (P=0.769), or reintervention rates (P=0.580). CONCLUSIONS: Cusp prolapse-driven by heterogeneous mechanisms-is prevalent in tricuspid aortic valve root aneurysms and reduces the likelihood of successful VSRR. Preoperative 3D TEE quantification of cusp pathology can aid in surgical planning. Despite lower preservation rates in prolapse patients, both groups achieved comparable midterm outcomes following judicious patient selection.