Advances in aortic valve repair: focus on functional approach, clinical outcomes, and central role of echocardiography.

The surgical classification of aortic regurgitation (AR) is based on cusp mobility. Based on this classification, there are 3 classes of AR: type I is defined as normal cusp mobility, type II is defined as excessive cusp mobility, and type III is defined as restricted cusp mobility. Patients often have multiple coexisting mechanisms. Because aortic valve (AV) repair is safe, effective, and durable, it likely will become a mainstream surgical option for the management of significant AR, even in the setting of a bicuspid valve. Intraoperative transesophageal echocardiography has a central role at all stages in AV repair. Before cardiopulmonary bypass, it can accurately diagnose the mechanism of AR to guide operative strategy for successful repair. After separation from cardiopulmonary bypass, it can comprehensively evaluate the AV repair, including the likelihood that the repair will be durable in the long-term. Important echocardiographic predictors of a durable AV repair include the absence of AR, cusp coaptation above the annular plane, a coaptation length >4 mm, and an effective cusp height >8 mm. The clinical applicability of AV repair continues to expand and likely will evolve into a mainstream surgical therapy for AR, including minimally invasive techniques.