1. Aortic Valve Repair

2. Aortic Root Annulus Cusp Sinus ST junction Sub Commissure Triangle

3. TEE Cusp number Diameter of annulus, S of Valsalva, STJ Cusp thickness Free margin Coaptation line Direction and size of Rergurgitation Jet Mechanism: Dissection, Aneurysm of Aortic root, Leaflet prolapse, Endocarditis, Degenerative

4. Repair For AI or Aortic Root Aneurism

5. Repair:When? limited to patients with (AR) without a component of stenosis. Repair may not be justified in older patients with excellent proven longevity of bioprostheses. Bicuspid valves may be less amenable to reparative techniques than tricuspid valves, because the calcification in the bicuspid valve is more diffuse from free margin to aortic wall Valve repair is an established part of the treatment armamentarium for aortic valvular disease but is a technique in evolution, requiring better definition of successful approaches.

6. The functional classification of aortic root abnormalities responsible for aortic insufficiency

7. Surgical procedures Type Ia: distal ascending aorta dilation, (STJ dilation)

8. Surgical procedures Type Ia lesions are treated by reduction of the circumference of the Sino-tubular junction and is usually achieved by replacing the ascending aorta with an appropriately sized Dacron graft. Ideally, its diameter should be approximately the size of the native aortic annulus Type Ia: distal ascending aorta dilation, (STJ dilation)

9. Type Ib: proximal (valsalva sinuses) dilation and STJ dilation

10. Bentall

11. Horizontal mattress sutures without pledges are placed in one lane underneath the sinuses for later fixation of the graft to the aortic root. Kallenbach K et al. MMCTS 2007;2007:mmcts.2006.001917 © 2007 European Association for Cardio-thoracic Surgery

13. Yacoub

17. David

18. Yacoub

19. Surgical procedures For the Type Ic the most appropriate surgical procedure may be a partial sub-commissural annuloplasty or circular annuloplasty Circular Annuloplasty Type Ic: isolated FAA dilation Commissural Annuloplasty

20. Reduction annuloplasty

21. Surgical procedures Type Id: cusp perforation and FAA dilation Type Id lesions are treated by patch closure. For large defects autologous tricuspid leaflet tissue is used rather than autologous pericardium in the hope that will remain free from calcification

22. Cusp Perforation

23. Surgical procedures Type II Cusp prolapse:The triangular resection The triangular resection involves excising a triangle of tissue in the middle of the prolapsing valve and then suturing the edges back together. A continuous suture is recommended instead of interrupted sutures because it decreases the chance of a leak and lessens thrombogenicity

24. Cusp Prolapse in Tricuspid Valve

25. Surgical procedures Type III Restrictive Cuspid motion Shaving, decalcification and valve extension with Three strips of pericardium, 3–8 mm that are sewn to the free edges of the valve cusps to extend them and increase the surface area for coaptation

27. Bicuspid Aortic Valve

28. Reoperation The Toronto group reported a 26% reoperation rate at 5 years in theirs series of 54 adults Surgeons at the Cleveland Clinic reported a 13% reoperation rate in a series of BAV patients We reported our experience at Mayo Clinic in 160 consecutive patients with indications for valve repair including a dilated annulus, BAV and trileaflet valve cusp prolapse [1]. At 5 years, the reoperation rate was 11% overall and 10%, 9% and 16% for dilated annulus, BAV and trileaflet valve cusp prolapse respectively.