REVIEW ARTICLE

Transesophageal Echocardiographic Evaluation During

Aortic Valve Repair Surgery
Michel J. Van Dyck, MD,* Christine Watremez, MD,* Munir Boodhwani, MD, MMSc,
Jean-Louis Vanoverschelde, MD, PhD, and Gebrine El Khoury, MD
For patients with aortic valve (AV) disease, the classic treatment has been AV replacement and
this remains true for aortic stenosis. In contrast, repair of isolated aortic insufficiency (AI), with
or without aortic root pathology, is emerging as a feasible and attractive option to replacement. The AV is one of the elements of the aortic root. As such, AI can develop if one or more
elements of the aortic root are diseased. Intraoperative transesophageal echocardiographic
evaluation permits analysis of the mechanisms of aortic regurgitation as well as differentiation
between repairable and unrepairable AV pathology. Immediate postrepair transesophageal
echocardiography provides important information about the quality and durability of repair
and identifies variables associated with recurrent AI. (Anesth Analg 2010;111:59 70)

ortic valve (AV) replacement has been until recently the standard surgical procedure for the
treatment of AV diseases. However, this trend is
progressively changing towards surgical repair in selected
cases.19 Initial attempts at AV repair, performed during
the 1960s and 1970s, consisted of commissurotomy, leaflet
shaving, pericardial patches, and leaflet extension in rheumatic valves.10 12 A greater understanding of the relationship between the AV and root in the 1980s contributed to
the development of valve-sparing aortic root replacement
techniques that allow for preservation of a normal native
valve when a diseased aortic root is replaced.4,9,13 More
recently, understanding of the functional interactions
among the aortic cusps, aortic annulus, subcommissural
triangles, and the sinotubular junction (STJ) has led to the
concept of tailored surgical repair of aortic insufficiency
(AI) with or without aortic root disease.14,15 In contrast,
even in the best series, repair of calcified and/or rheumatic
AVs is limited because of the high rate of recurrent cusp
restriction, restenosis, or patch dehiscence.2,16 18 There is
an increasing interest in the use of AV sparing and valve
repair for the treatment of AI with the advantages of
eliminating the need for long-term anticoagulation and
reducing the risk of the prosthesis-related complications of
thromboembolism, endocarditis, bleeding, and structural
valve deterioration. Repair also has a comparatively low
operative mortality and a good midterm durability2,3,19 21
and, in children, has the additional advantage of allowing
for growth, delaying for several years the need for AV
replacement.22,23
Multiple imaging modalities, e.g., magnetic resonance
and computed tomography, are useful for the preoperative

assessment of AI. However, intraoperative transesophageal

echocardiography (TEE) is uniquely suited to identify those
AI lesions that are suitable for repair based on valve
anatomy and an analysis of the mechanisms of incompetence.15,16,24 Furthermore, an immediate postrepair evaluation provides important information about the quality of
the surgical repair and mechanisms of any residual AI.
In this article, we review a mechanistic classification of
AI accompanied by the typical echocardiographic appearance of each pathophysiologic mechanism, and describe the
surgical repair techniques along with their echocardiographic appearance. Lastly, we discuss the key echocardiographic features that constitute an optimal postoperative
result.

From the Departments of *Anesthesiology, Cardiovascular Surgery, and

Cardiology, Cliniques universitaires St-Luc, Universite catholique de Louvain, Brussels, Belgium.

When dealing with intraoperative pre cardiopulmonary

bypass (CPB) evaluation of repairability of a regurgitant
AV, quantification of the insufficiency is less important
than the analysis of its mechanism performed in the
presence of the surgeon.15 These patients have frequently
been evaluated with numerous cardiac imaging modalities that have led to the decision for surgical intervention. Prerepair TEE should thus focus on a careful
analysis of the aortic cusps, analysis of the direction of the
AI jet, and measurements of the aortic root diameter3133
(Fig. 2). The general assessment of the AV anatomy and

Accepted for publication February 15, 2010.

Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals Web site (www.anesthesia-analgesia.org).
Address correspondence and reprint requests to Michel J. Van Dyck, MD,
Department of Anesthesiology, Cliniques universitaires St-Luc, Universite
catholique de Louvain, Avenue Hippocrate, 10-1821, B-1200 Brussels, Belgium. Address e-mail to michel.vandyck@uclouvain.be.
Copyright 2010 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3181dd2579

July 2010 Volume 111 Number 1

ANATOMY OF THE AV AND ROOT

The aortic root acts as a native stent, surrounding and
supporting the 3 aortic cusps. It extends from the basal
attachments of the cusps within the left ventricle (the basal
ring or ventriculoaortic junction [VAJ], that refers to the
aortic annulus measured with echo) to their distal attachment at the STJ. Because of the crown-like semilunar
attachment of the leaflets within the sinuses of Valsalva, 3
interleaflet triangles separate each cusp (Fig. 1).
Detailed anatomy of the valve has been reviewed,2530
but it is important to understand that, functionally, the
leaflets, the annulus, and the STJ are integral parts of the
valve mechanism. Therefore, all of these elements need to
be considered in determining the mechanism of AI and for
tailored surgical correction.

PREREPAIR ECHOCARDIOGRAPHIC ANALYSIS OF

THE AV AND ROOT

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Figure 1. Diagram of the aortic root. The

2 borders of the root are drawn: the
sinotubular junction and the ventriculoaortic junction. The basal attachment
of the aortic cusps forms the basal ring
and is also often described as the
aortic annulus. Inset: The crown-like
shape of the valve attachments determines the presence of 3 interleaflet
triangles. (Modified from Sutton et
al.,30 with permission.)

Figure 2. Normal aortic root in the midesophageal aortic valve

long-axis view at end diastole. a, Measurements are made at 4
levels: (1) the aortic annulus, (2) the widest cross-section at the
sinuses of Valsalva, (3) the sinotubular junction, and (4) the
ascending aorta 1 cm beyond the sinotubular junction. b, In this
case, the coaptation length is 8.5 mm and its height reaches the
midportion of the sinuses of Valsalva. LA left atrium; LVOT left
ventricular outflow tract; Ao ascending aorta.

function is detailed in a Web supplement (see Supplemental

Digital Content 8, http://links.lww.com/AA/A132) and illustrated in video clips 1 (see Supplemental Digital Content 2,
http://links.lww.com/AA/A126), 2 (see Supplemental Digital
Content 3, http://links.lww.com/AA/A127), and 3 (see Supplemental Digital Content 4, http://links.lww.com/AA/A128; see
Appendix for video captions.).

POSTREPAIR TRANSESOPHAGEAL
ECHOCARDIOGRAPHIC ANALYSIS
As with any valve repair procedure, one of the primary roles
of TEE is the immediate evaluation of the quality of the repair.
The expected postoperative result is a flexible valve that opens
well and is competent without residual insufficiency.
Before aortic cross-clamp release, the effectiveness of the
repair can be estimated by administering a terminal dose of
blood cardioplegia into either the aortic root or tube graft. The
root pressurization will oppose the cusps against each other.
This technique has been described in pediatric cases of AV

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repair34 but is sometimes difficult because the empty nonbeating cardiac structures are not always easily identified at that
time.
After the aorta has been unclamped, the pressure caused
by the CPB through the aortic cannula into the aortic root will
unmask any defect of coaptation. Any significant residual AI
at that time indicates an unsatisfactory repair.
Based on a retrospective analysis of the intraoperative
echocardiographic data in 186 patients who underwent AV
repair, le Polain de Waroux et al.35 established the following stepwise algorithm incorporating functional and morphological features measured immediately after weaning
from CPB. First, the level of cusp coaptation should be
above the aortic annulus. This means that the lower level of
the coaptation should be higher than the VAJ and its
highest level should approach the midheight of the sinuses
of Valsalva. The second step consists of evaluating the
presence and the direction of any residual AI. Finally, in
patients who have a level of coaptation above the aortic
annulus and who do not have any significant AI, the
third step consists of measuring the coaptation length. In
this study, a postrepair coaptation length 4 mm was
strongly associated with an increased risk of subsequent
recurrent AI.
These observations are in agreement with other studies
that also confirmed the importance of postrepair cusp
coaptation. Pethig et al.36 showed that after valve-sparing
procedures, the lowest part of the coaptation should be
higher than the aortic annular graft implantation; otherwise, it could lead to a recurrent AI necessitating reoperation. Schafers et al.37 have designed a special caliper that
allows measuring the effective cusp height, i.e., the
height difference between the highest coaptation point of
the cusps and their aortic insertion. Based on their observation that patients who subsequently needed reoperation
for AI with recurrence of cusp prolapse had an abnormally
low (4 6 mm) height difference compared with the other
patients (8 11 mm), they consistently aim at achieving an
effective height of 9 to 10 mm.
In case of any residual AI after AV repair surgery, the
echocardiographer should quantify it according to the
guidelines of the American Society of Echocardiography
(Table 1 and see Web supplement)38 and attempt to identify
its mechanism.

ANESTHESIA & ANALGESIA

TEE During Aortic Valve Repair

Table 1. Doppler Methods for Aortic

Insufficiency Evaluation
Moderate

Jet width/LVOT
width (%)
PHT (ms)
R (cm)
EROA (cm2)
Regurgitant volume
(mL/beat)
Vena contracta
width (cm)

Mild
25
500
0.3
0.10
30

Mild to
Moderate
2545

Moderate to
Severe
4565

200500
0.40.6
0.70.9
0.10.2
0.20.3
3044
4560

0.3

0.30.6

Severe
65
200
1
0.3
60
0.6

EROA effective regurgitant orifice area; LVOT left ventricular outflow tract;
PHT pressure half time; R radius.
Jet width relative to LVOT width and vena contracta width are to be measured
at Nyquist limit of 50 to 60 cm/s.

Whether or not they are reimplanted, because the surgeon places sutures within the aortic root, the coronary
arteries can be damaged. The echocardiographer should be
aware of such possible injury and look for regional wall
motion abnormalities and, if possible, to visualize blood
flow in the proximal segments of the coronary arteries.
Because valve repair can reduce the valve opening, mean
and peak transvalvular gradients should be measured in the
operating room to exclude significant stenosis. Mean and
peak gradients in excess of 15 and 30 mm Hg, respectively, are
considered unsatisfactory and could be associated with higher
risk of developing severe aortic stenosis necessitating reoperation.24 Caution is necessary when measuring pressure
gradients in the operating room because these gradients are
highly flow dependent and thus under the influence of the
patients hemodynamic status.
If the repair is judged unsatisfactory, a thorough echocardiographic analysis of the valve is absolutely critical and
will guide the surgeon in an attempt to correct the causes of
residual AI during reexploration. In addition to the postrepair appearance and function of the valve, the decision to
reexplore the valve after repair depends on a number of
valvular factors including the underlying mechanism of AI,
the aggressiveness of attempted repairs, the quality of
valve tissue, and a variety of patient factors including age,
patient comorbidities, choice of prosthesis (if replaced), and
left ventricular function.16 In cases in which repair is
judged to be no longer feasible, the decision may be made
to replace the valve.

ECHOCARDIOGRAPHIC DESCRIPTION OF
VARIOUS CAUSES OF AI
Functional Classification of AI
In 1997, Haydar et al.39 defined, in a largely pediatric population, type I AI in the presence of an aortic annular dilation,
whereas type II AI was the result of redundant leaflet tissue
and type III of restricted leaflet motion. El Khoury et al.33
further refined this classification by considering the aortic root
as a functional entity with two borders (the VAJ and the STJ).
They also further divided type I into subtypes based on
which root component was dilated. This classification
focuses on the mechanism of valve dysfunction and

July 2010 Volume 111 Number 1

helps the surgeon choose the most appropriate repair

technique to restore normal valve physiology8 (Fig. 3).
Preoperative assessment of the functional anatomy by
TEE has proven to be an accurate and strong predictor of
valve repairability and postoperative outcome.16 The following sections discuss the various mechanisms of AI
along with the surgical techniques used and postrepair
echocardiographic analysis.

Type I: Dilation of the Functional Aortic Annulus

Type IA: STJ Dilation and Ascending Aortic Aneurysm
Dilation of the ascending aorta distal to the aortic root
will not cause AI unless there is associated dilation of the
STJ40 (video clip 4, see Supplemental Digital Content 9,
http://links.lww.com/AA/A133; see Appendix for video
captions.).

TEE. End diastolic measurements made in the

midesophageal (ME) AV long-axis (LAX) view confirm
that the aortic annulus and the sinuses are not dilated
whereas the ascending aorta and the STJ are enlarged.
Evaluation of the aortic arch and the descending aorta is
recommended to confirm whether these structures are
also involved in the dilation.
Color flow Doppler shows central AI jet parallel to the
left ventricular outflow tract (LVOT). In the short-axis
(SAX) view of the valve, the origin of the jet is central.
Surgical correction. Surgical correction aims at restoring a normal STJ7 and replacing the aneurysmal portions of the thoracic aorta. Surgery will typically consist
of a supracoronary ascending aortic replacement with a
Dacron graft. A key surgical decision in these cases is
the sizing of the prosthesis, because an undersized
prosthesis may induce cusp prolapse resulting in AI. In
the setting of significant preoperative AI, subcommissural annuloplasty sutures are sometimes added to
stabilize the proximal portion of the functional aortic
annulus and increase the leaflet coaptation surface.2,3
Postrepair TEE. The AV and the native sinuses of
Valsalva have been preserved, along with the coronary
arteries. The tubular aspect of the Dacron graft is clearly
visualized as 2 striated parallel lines attached to the STJ.
A postrepair eccentric AI jet in this setting may be
attributable to previously undetected cusp prolapse or
induced prolapse caused by an undersized prosthesis.
Type IB: Aneurysms of the Aortic Root
In such cases, the VAJ and the sinuses of Valsalva are dilated
and the STJ is effaced (video clip 5, see Supplemental Digital
Content 10, http://links.lww.com/AA/A134; see Appendix
for video captions.). The dilation of the aortic root causes an
outward displacement of the valve commissures and thus a
tethering of the leaflets, which do not coapt adequately during
diastole. This appearance is typical of Marfan or EhlersDanlos disease and other diseases of the aortic media.41,42
Patients with bicuspid AVs can also present with aortic wall
abnormalities that can lead to such aortic root dilation.43,44
The AI caused by these aortic pathologies increases aortic
stroke volume that, together with structural changes in the

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Figure 3. Repair-oriented functional classification of aortic insufficiency (AI) with

description of disease mechanisms and
possible repair techniques. FAA functional aortic annulus; STJ sinotubular
junction; SCA subcommissural annuloplasty. (From Boodhwani et al.,15 with
permission.)

Figure 4. Illustration of 2 surgical techniques for valve-sparing aortic root replacement. a, The sinuses of Valsalva have
been removed up to the annulus, only
keeping the aortic valve leaflets and their
commissures. The coronary arteries have
been detached. b, Remodeling technique:
the sinus segments are replaced with a
scalloped graft. c, Reimplantation technique: the valve and its annulus are reimplanted into a tube graft, here a Valsalva
prosthesis.

aortic wall, contribute to further dilate all the components of

the aortic root and aggravate the AI.45,46

TEE. The pathology also involves the ascending aorta,

and the aortic leaflets can be normal. Transesophageal
echocardiographic analysis in the ME AV SAX view
shows a central defect in coaptation and the ME AV
LAX view shows that the coaptation length is reduced.
Color flow Doppler will show the associated AI,
which has a central origin in the SAX and a central
direction, parallel to the LVOT, in the LAX.
Surgical treatment of aneurysms of the aortic root
historically consisted of root replacement with replacement of the AV (Bentall procedure). However, a valvesparing aortic root replacement is now becoming the
preferred procedure to manage this pathology. Numerous techniques have been described, but the following 2
are used most often (Fig. 4).
The remodeling technique consists of replacing the
sinuses of Valsalva and the ascending aorta with an
appropriately tailored graft fitting between the native
commissures.7,13,28,47,48 Sizing of the graft is based on
the diameter of the STJ. In the reimplantation procedure, the native aortic cusps and their commissures are
reimplanted inside a tubular Dacron graft that replaces
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the diseased sinuses and the aneurysmal part of the

ascending aorta.4,49 This technique is sometimes preferred because it provides more stable valve function
and prevents further dilation of the VAJ.9,19 Certain
benefits have been proposed for the creation of neoaortic sinuses in the tube graft.50 52 This can be done by
plication of the Dacron graft in the spaces between the
commissures or by anastomosing 2 Dacron grafts of
different sizes.9,19 Recently, a prosthesis with built-in
sinuses (Gelweave Valsalva, Vascutek/Terumo, Inchinnan, Renfrewshire, Scotland) has been developed,
which attempts to restore an almost normal anatomy
and functional appearance of the aortic root.5355 Sometimes, only 1 sinus is diseased, giving an asymmetrical
appearance to the AV in both the SAX and LAX views.
In such cases, only the diseased sinus can be replaced
using a teardrop-shaped patch.56
Postrepair TEE. A tubular prosthesis looks like a
cylinder that can be followed down to the aortic annulus. When a Valsalva prosthesis with built-in sinuses is
used for aortic root replacement, its typical shape can be
easily appreciated in either the ME AV LAX view or the
transgastric LAX and deep transgastric LAX views.
ANESTHESIA & ANALGESIA

TEE During Aortic Valve Repair

Figure 5. Aortic cusp prolapse, midesophageal aortic valve long-axis

views. a, Eccentric aortic regurgitant jet directed posteriorly (toward the
anterior mitral leaflet). Such an orientation suggests a prolapse of the
right coronary cusp. b and c, Eccentric jet directed anteriorly, as seen in
the case of a prolapse of the noncoronary cusp (b) or of the left coronary
cusp (c). This latter patient also presented with an eccentric mitral
regurgitation (MR) jet. In such cases of anteriorly directed jets, analysis
of the cusps in the midesophageal aortic valve short-axis view or with
3-dimensional echocardiography can help in localizing the prolapsing
cusp. LA left atrium; Ao ascending aorta.

The prosthetic neo-sinuses appear larger than either the aortic annulus or the ascending prosthesis.
Type II: Cusp Prolapse
One or more leaflets can prolapse into the LVOT because
of either excessive tissue or commisural disruption
(video clip 6, see Supplemental Digital Content 11,
http://links.lww.com/AA/A135; see Appendix for video
captions.).
Transesophageal Echocardiography
Cusp prolapse is defined when the free edge of 1 or more
aortic cusps overrides the plane of the aortic annulus. As in
mitral valve prolapse, the resulting regurgitant jet is eccentric and directed in the opposite direction. A prolapse of the
right coronary cusp (RCC) will give rise to a jet directed
posteriorly, but a prolapse of any of the posterior cusps will
cause an anteriorly directed jet32,33 (Fig. 5). Because the
posterior cusp in the ME AV LAX view can be either the left
coronary cusp (LCC) or the noncoronary cusp (NCC), only

July 2010 Volume 111 Number 1

Figure 6. Representative examples of the 3 subtypes of cusp prolapses in

the midesophageal aortic valve long-axis view. a, Partial prolapse of the
right coronary cusp with midcusp bending (arrow). b, Whole prolapse of the
right coronary cusp. c, Eversion of the right coronary cusp (flail).

the SAX analysis of the AV (or the simultaneous display of

orthogonal planes) will help to distinguish between a
prolapse of either the LCC or the NCC.
Cusp prolapse can be further categorized into 3 subtypes16: partial cusp prolapse, whole cusp prolapse, and
flail cusp (Fig. 6).
Partial cusp prolapse is the prolapse into the LVOT of
the distal part of a cusp. This is often associated with a clear
bending of the cusp body visible in both the LAX and SAX
views and also intraoperatively by the surgeon (Fig. 7). This
fold is typically fibrous and thickened, which could be
attributable to the diastolic pressure exerted on a weaker
redundant cusp.
Whole cusp prolapse is defined as the free edge of the
cusp overriding the plane of the aortic annulus, with the
entire body of the cusp billowing into the LVOT. This
billowing can be appreciated as a circular structure in the
SAX view of the LVOT, immediately below the valve.

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conjunction with aortic root or ascending aortic dilation,

the dilated portions of the aorta are replaced and this serves
to stabilize the functional aortic annulus, preventing further dilation. In the setting of isolated cusp prolapse, cusp
repair is typically accompanied by a subcommissural
annuloplasty performed at the level of the interleaflet
triangles, with the aim of stabilizing the annulus similar to the
prosthetic annulus placed in mitral valve repair. This technique also serves to increase cusp coaptation surface.
Postrepair TEE
The resuspension suture performed at the free margin
of the prolapsing cusp can be appreciated in both the
SAX and LAX views as a striated, more echogenic
aspect of the leaflet. Cusp plication will thicken the
middle part of the free edge of the leaflet. The pledgets of
a subcommissural annuloplasty are sometimes visible
by TEE as dense structures at the level of the commissures, below the coaptation level (see all these aspects
on video clips 4 [http://links.lww.com/AA/A133], 6
[http://links.lww.com/AA/A135], and 7 [http://links.lww.
com/AA/A136]; see Appendix for video captions.). One should
be aware that this could limit the valve opening and therefore it
is useful to measure the systolic pressure gradient across the
repaired valve.

Type III: Cusp Restriction

The aortic cusps can be affected by any rheumatic or
degenerative disease that causes commissural fusion, fibrous thickening, and cuspal retraction, potentially causing
some stenosis and incomplete valve closure causing AI.
These lesions are different from calcifications that usually
affect the cusp tissue itself. AI in these type III cases is
usually central and, because the valve is stiffer, typically
originates higher in the sinuses of Valsalva.32
Endocarditis can also be responsible for valve destruction
and may present with perforation, vegetations, and other
associated pathology. With adequate preoperative antimicrobial treatment, cusp perforations in this setting can sometimes
be repaired, avoiding the use of an artificial prosthesis.
Figure 7. The typical fold (arrow bending) of a prolapsing right
coronary cusp (RCC) as seen echocardiographically in both the
midesophageal aortic valve long-axis (a) and short-axis (b) views, and
intraoperatively by the surgeon (c). LA left atrium; NCC
noncoronary cusp; LCC left coronary cusp.

Cusp flail occurs when there is a complete eversion of

the cusp into the LVOT in the LAX view.
Sometimes, the AI jet is eccentric without evidence of
cusp prolapse; careful inspection of the free edge of the
affected cusp both in gray scale and color Doppler can
disclose a small tear along the margin corresponding to a
fenestration. Rupture of a fenestration can also present with
similar findings as cusp prolapse with an eccentric jet.16
Surgical Correction
Various surgical techniques are used to repair a prolapsing
aortic cusp.2,3,33,5759 Central plication, triangular resection,
or implantation of a pericardial patch may be used. Free
margin resuspension, using a polytetrafluoroethylene suture can also be used to shorten and elevate the free margin
and improve coaptation.59,60 When cusp prolapse occurs in

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Transesophageal Echocardiography
The valve is thickened, more echogenic, and sometimes
contains calcifications. The commissures are fused and the
valve opening is reduced (Fig. 8). Systolic leaflet doming
can be present, i.e., the leaflets are concave toward the
center of the aorta during systole, and any degree of aortic
stenosis should be quantified by Doppler measurements in
the transgastric views.
A precise echocardiographic analysis of the cusps helps
to determine the repairability of the valve. Some authors
have proposed a grading of aortic calcifications16,61 extending from grade 1 (no calcifications) to grade 4 (extensive
calcifications of all cusps with restricted cusp motion).
Aortic repair seems to be more often feasible when calcification severity is less than grade 3 and when calcifications
are confined to the free margins instead of involving the
body of the cusps. Such findings have also been described
for bicuspid AVs.62
Surgical Correction
Type III valves are the most difficult to repair appropriately
and more prone to late repair failure and recurrent AI.16

ANESTHESIA & ANALGESIA

TEE During Aortic Valve Repair

Figure 8. Thickened aortic valve (type III).

The free margins of the aortic cusps are
thickened as seen in the midesophageal
aortic valve short-axis (a) and long-axis (b)
views, and confirmed by 3-dimensional
epicardial echocardiography (c) and intraoperatively by the surgeon (d). LA left
atrium; RA right atrium; LV left
ventricle; Ao ascending aorta; NCC
noncoronary cusp; LCC left coronary
cusp; RCC right coronary cusp.

Surgery is tailored to the pathology encountered and may

consist of shaving the thickened margins of the cusps,
enucleation of hypertrophied nodes of Arantius, decalcification, commissurotomy of fused commissures, or even
cusp extension.3,18,63 Certain cusp defects can also be
repaired by autologous or bovine pericardium.10,11 Good
long-term results can be obtained by an individualized
approach in selected patients.63
Postrepair TEE
The valve should be mobile, open widely, without any
significant gradient and coapt without residual AI. The
patches used for perforated cusp closure or cusp extension
can sometimes be visualized as more mobile structures that
are circular in the SAX view.

Multifactorial Causes of AI
Sometimes AI is caused by multiple mechanisms; a
cusp prolapse can be associated with aortic root dilation
or could appear after a valve-sparing procedure (video
clips 7 [http://links.lww.com/AA/A136] and 8
[http://links.lww.com/AA/A137]; see Appendix for
video captions.). Chronic aortic root dilation may alter
the dimensions of the valve leaflets, necessitating correction of both the root dilation and the leaflet free-edge
length to achieve a competent valve.64 A prolapsing cusp
can also present with fenestrations. In such cases, all
causative lesions should be corrected simultaneously to
ensure a good result.8,65 67 It is therefore of paramount
importance to examine both the valve and the ascending
aorta as part of a complete and systematic transesophageal echocardiographic evaluation.

July 2010 Volume 111 Number 1

THE BICUSPID AV
Bicuspid AVs are often associated with other pathologies such
as coarctation of the aorta, patent ductus arteriosus, ventricular septal defects, and anomalous origin of the coronary
arteries43 (video clip 8 [http://links.lww.com/AA/A137]).
This congenital pathology of the valve leaflet formation has a
familial occurrence. In addition, it has been associated with
abnormalities of matrix metalloproteinases within the aortic
wall leading to loss of smooth muscle in the ascending aortic
media, causing aortic root dilation, aneurysm formation, and
dissection.44 In addition, calcification of a bicuspid valve is
accelerated in comparison with a tricuspid AV,68,69 and the
valve is more prone to insufficiency and endocarditis.

Transesophageal Echocardiography
The preoperative analysis of the valve should define the
orientation of the coaptation line and the presence of a
raphe. The most common bicuspid valve (type 1) is asymmetrical and presents with a median raphe and rudimentary commissure.70 Fusion of the LCC and RCC is most
common, and a fusion of the RCC and the NCC is more
often associated with moderate or severe aortic stenosis
and/or AI.71 However, type 0 bicuspid valves are symmetrical and have neither raphe nor rudimentary commissure and tend to have more aberrant coronary anatomy. All
aspects of the valve should be examined with TEE to help
the surgeon determine its repairability.72 One study has
shown that transesophageal echocardiographic factors associated with a higher chance of bicuspid valve repairability were the presence of an eccentric jet (type II, cusp
prolapse) and the absence of cusp thickening, cusp calcification, or commissural thickening.62 All types of AI mechanisms can be observed when dealing with bicuspid AVs:

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cusp prolapse (type II), aortic root dilation (type I), thickening and restriction of the cusps (type III), calcification of
the raphe, commissural fusion, and even perforation due to
endocarditis.

Surgical Procedures
Bicuspid valve anatomy appears to facilitate leaflet repair
because only a single coaptation line has to be appreciated.
However, the regurgitant bicuspid AV is the perfect example of why both the valve and all the components of the
aortic root complex have to be addressed and repaired
together. Valve repair will realign the height of the leaflets
and usually consists of plication of the free margin or
triangular resection of the raphe with or without placement
of a pericardial patch3,73,74 and leaflet free-edge resuspension. Subcommissural annuloplasty and STJ remodeling are
occasionally used to maintain an ideal relationship between
the annulus and the STJ.73,75 Because of the increased rate
of aortic root dilation,76 it is generally accepted that the
ascending aorta should be replaced if its diameter exceeds
5 cm.77 In the setting of valve repair, however, an even
more aggressive stance (4.5 cm) has been proposed to
replace the aortic root because it serves to stabilize the cusp
repair and prevent further dilation of the aortic annulus.42,78 80 Both root remodeling and root reimplantation
techniques can be used. Repair of diseased bicuspid AVs or
preservation of functionally normal bicuspid valves during
surgery for aortic aneurysm both have demonstrated acceptable midterm durability.37,75,81

Postrepair TEE
The repaired leaflet can be somewhat stiffer, with a typical
bicuspid appearance. It should present both a satisfactory
opening without a significant gradient82,83 and an appropriate level of coaptation37,73 without residual AI.

THE QUADRICUSPID VALVE

The quadricuspid valve has a rare occurrence rate of
1% in patients presenting for AV surgery and leads
to early valve stenosis and/or AI. Although most
reported cases ended up having a valve replacement,84 some have successfully been repaired85,86
(video clip 9, see Supplemental Digital content 14,
http://links.lww.com/AA/A138; see Appendix for video
captions.).

Transesophageal Echocardiography
The examination should focus on the relative dimensions
and mobility of the 4 cusps, the presence of a rudimentary
commissure, and on the analysis of the mechanism of AI
(restriction versus prolapse).

Surgical Procedures
The valve can be rendered tricuspid by resection of the
commissural fusion and suturing of the 2 smaller cusps into
1 larger cusp. A pericardial patch is sometimes used to
augment the neocusp tissue.

Postrepair TEE
The valve is asymmetrical with a larger reconstructed cusp,
its opening is almost normal, and little or no insufficiency
should be seen in either the SAX or LAX view.

66

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CONCLUSION
TEE is a mandatory diagnostic and monitoring tool during
any AV repair or valve-sparing surgery. Careful preoperative anatomic assessment of the valve and the aortic root,
along with analysis of the origin and the direction of the
regurgitant jet, aids in understanding of the AI mechanism.
The use of a functional AI classification predicts repairability
and enables a systematic repair strategy, thereby helping the
surgeon achieve a better and longer-lasting postoperative
result. Intraoperative echocardiography can be used to
evaluate the success of repair involving all of the emerging
surgical techniques described, with the immediate postoperative goal of optimal height and length of cusp coaptation
and little or no residual AI.

APPENDIX: VIDEO CAPTIONS

Video Clip 1, analysis of the aortic valve. A, ME AV SAX view. Left,
Midesophageal aortic valve short-axis view of a normal aortic valve.
The 3 cusps are identified. Right, Color flow Doppler shows no aortic
insufficiency during diastole. B, ME AV LAX view. Left, Midesophageal aortic valve long-axis view of a normal aortic root. The shape of
the root is normal and the sinotubular junction is well depicted.
Right, Color flow Doppler shows no aortic regurgitation during
diastole. C, Still frame, ME AV LAX view. Normal aortic root in the
midesophageal aortic valve long-axis view at end diastole. Measurements are made at 4 levels: A, the aortic annulus; B, the widest
cross-section at the sinuses of Valsalva; C, the sinotubular junction;
and D, the ascending aorta 1 cm beyond the sinotubular junction. D,
Still frame, ME AV LAX view. The cusp coaptation is depicted
(blinking bar) and its highest part reaches the midportion of the
sinuses of Valsalva (line B). Ao ascending aorta; LA left atrium;
LV left ventricle; LVOT left ventricular outflow tract; NCC
noncoronary cusp; LCC left coronary cusp; RCC right coronary
cusp; PV pulmonary valve; RA right atrium; RV right ventricle.
Video Clip 2, aortic insufficiency (AI) analysis and quantification
in the ME AV LAX view. All the following loops and still frames
correspond to the same patient with aortic insufficiency. A, Still
frame. Measurement of the vena contracta in the ME AV LAX view.
The vena contracta is measured at the narrowest portion of the jet,
which is usually at the level of the aortic valve, immediately below
the flow convergence region. B, Still frame. Measurement of the AI
jet/LVOT width ratio in the ME AV LAX view, color M-mode. This mode
of assessment of AI severity is based on the ratio of the maximal
proximal jet width to the left ventricular outflow tract diameter
immediately below the aortic valve, within 1 cm of the valve. The
measurements should be done at the same point of time and this
method tends to underestimate the severity of eccentric jets.
Video Clip 3, aortic insufficiency (AI) analysis and quantification
in the transgastric (TG) views. Two TG views can help to analyze the
aortic valve and to help in aortic insufficiency quantification. A, Deep
TG LAX view. Left, Obtained at 0 by TG approach, this view, similar
to the apical 4-chamber view obtained by transthoracic echo, permits
vertical alignment of the left ventricular outflow tract, the aortic valve,
and the aortic root. A detailed anatomic assessment of the valve is
difficult but sometimes feasible allowing analysis of the cusp
coaptation (see also video clip 6). Right, Good alignment with color
flow Doppler allows for analysis of the flow across the aortic valve
during both systole and diastole. However, the intensity of the
regurgitant jet may be underappreciated. B, TG LAX view. Obtained by
rotation of the transducer from 0 to 160, this view also sometimes
permits flow analysis across the aortic valve. Gradient measurement: It is often feasible to align the continuous wave (CW) Doppler
beam with the aortic outflow in 1 of the 2 TG views described above.
This allows one to measure peak and mean velocities through the
aortic valve and hence to calculate peak and mean gradients. C, Still
frames TG LAX view. In this case of pure aortic insufficiency, parallel
alignment of the Doppler beam permitted measurement of a systolic
mean velocity of 102 cm/s and peak velocity of 150 cm/s corresponding respectively to mean and peak gradients of 4.8 and 8.9
mm Hg. D, Still frames: pressure half-time (PHT) measurement. PHT
corresponds to the rate of deceleration of the diastolic regurgitant jet

ANESTHESIA & ANALGESIA

TEE During Aortic Valve Repair

and reflects the rate of equalization of aortic and left ventricular

pressures. In this case, PHT is measured at 498 milliseconds
corresponding to a moderate aortic insufficiency. PISA measurements. E, TG LAX view. After a TG long-axis view has been obtained,
zoom is applied to the aortic valve and the Nyquist limit of the
aliasing velocity is shifted toward the direction of flow (in this case at
39 cm/s). The radius of the hemispheric shell of the aliased velocity
is then measured. F, Still frame. CW Doppler is applied to the
regurgitant jet and an envelope is traced. Peak AI velocity and the
velocity time integral (TVI) are so measured and allow calculation of
both the effective regurgitant area (EROA) and the regurgitant
volume. Ao ascending aorta; AoV aortic valve; EROA effective
regurgitant orifice area; LA left atrium; LV left ventricle; Mi V
mitral valve; PISA proximal isovelocity surface area; RV right
ventricle; TVI time velocity integral.
Video Clip 4, type IA: ascending aorta dilation starting from
above the sinotubular junction and extending to the aortic arch,
surgically corrected by supracoronary tube graft replacement of the
aorta and subcommissural annuloplasty. A, ME AV LAX view. Left,
Midesophageal aortic valve long-axis view shows a dilation of the
ascending aorta. Right, Color Doppler interrogation shows a central
aortic regurgitant jet, parallel to the left ventricular outflow tract
(LVOT). B, ME AV SAX view. Midesophageal aortic valve short-axis
view (zoom) with color Doppler interrogation shows that the regurgitant jet originates centrally, through a defect of coaptation caused by
tethering of the 3 leaflets. C, Still frame 1: ME AV LAX view.
Measurements performed at the level of the sinuses of Valsalva
(diameter 3.4 cm) and the sinotubular junction (STJ) (diameter, 3.3
cm) are within normal range whereas the diameter of the ascending
aorta 1 cm above the STJ is enlarged (5.5 cm), confirming that the
dilation starts above the STJ. D, Still frame 2: midesophageal
ascending aortic long-axis view. The aortic diameter at that level is
7.34 cm. In this patient, the dilation extended to the origin of the
left subclavian artery. E, Surgical repair. Surgery consisted of
the replacement of the aorta by a tube graft extending from the
sinotubular junction to the origin of the left subclavian artery. The
arch was replaced and the great vessels were reimplanted under
deep hypothermic circulatory arrest. Three subcommissural annuloplasty sutures were also performed to stabilize the aortic annulus
and increase cusp coaptation. F, ME AV SAX view. In this midesophageal aortic valve short-axis zoom view, 2 of the 3 subcommissural
annuloplasties are seen (arrows). G, ME AV LAX view. Left,
Midesophageal aortic valve long-axis view shows that the native
aortic sinuses have been preserved and that the ascending aorta
has been replaced by a tube graft. The corrugated aspect of the graft is
clearly seen (arrowheads). Right, Color Doppler interrogation shows no
residual aortic insufficiency after surgery. Ao ascending aorta; LA
left atrium; LV left ventricle; LVOT left ventricular outflow tract;
native Ao S native aortic sinuses of Valsalva; NCC noncoronary
cusp; LCC left coronary cusp; RCC right coronary cusp; RA right
atrium; RV right ventricle; STJ sinotubular junction.
Video Clip 5, type IB: dilation of the entire aortic root, surgically
corrected by an aortic valve-sparing root replacement (reimplantation
technique) with a Valsalva prosthesis. A, ME AV LAX view. Left,
Midesophageal aortic valve long-axis view in a patient who presented
with an aneurysmal dilation of the entire aortic root (arrowheads).
There is also a small amount of pericardial effusion. Right, Color
Doppler shows severe aortic insufficiency. B, Still frame ME AV LAX
view. Because of the tethering of the leaflets, there is a central
defect of cusp coaptation (blue arrow). C, ME AV SAX view. Left,
Midesophageal aortic valve short-axis view. Because of the tethering
of the leaflets, there is a central defect of cusp coaptation (blue
arrow). Right, Color Doppler interrogation confirms the central origin
of the aortic regurgitant jet (blue arrow). D, Surgery. Surgical repair
consisted of a valve-sparing aortic root replacement using the
reimplantation technique. In this case, a Valsalva type of prosthesis has been used. E, ME AV LAX view. Midesophageal aortic valve
long-axis view. Postoperatively, the neo-sinuses are well visualized
(arrowheads). Color Doppler interrogation shows no residual aortic
insufficiency. The Figure in the right lower part of the video shows
the normal aspect of a Gelweave Valsalva prosthesis
(Vascutek/Terumo, Inchinnan, Renfrewshire, Scotland, with permission). Ao ascending aorta aneurysm; LA left atrium; LVOT left
ventricular outflow tract; LCC left coronary cusp; NCC noncoronary cusp; RCC right coronary cusp; RV right ventricle.

July 2010 Volume 111 Number 1

Video Clip 6, type II: cusp prolapse corrected by subcommissural

annuloplasty and free margin plication of the right coronary cusp. A,
ME 4-chamber view. Left, Midesophageal 4-chamber view shows
prolapse and thickening of the right coronary cusp (yellow arrow).
Right, Color Doppler interrogation shows an eccentric aortic regurgitant jet directed toward the anterior mitral leaflet. B, ME AV LAX view.
Left, Midesophageal aortic valve long-axis view shows a partial
prolapse of the right coronary cusp with a thickened band (yellow
arrow) and a resulting loss of coaptation. Right, Color Doppler
interrogation shows an eccentric aortic regurgitant jet directed
posteriorly toward the anterior mitral leaflet. C, ME AV SAX view. Left,
Midesophageal aortic valve short-axis view depicts the thickening of
the right coronary cusp (yellow arrow). Right, Color Doppler interrogation shows that the regurgitant jet originates along the right
coronary cusp and is directed posteriorly toward the commissure
between the left and the noncoronary cusps. D, Still frame. The
thickened band is shown (yellow arrow) in both the left view
(midesophageal aortic valve long-axis) and right view (midesophageal aortic valve short-axis). E, Deep TG view. Left, Deep transgastric
view shows the loss of coaptation of the aortic valve (blue arrow).
Right, Color Doppler interrogation shows an eccentric regurgitant jet
directed toward the mitral valve. F, Surgical repair. Surgery consisted
of free margin plication of the right coronary cusp and 3 subcommissural annuloplasty sutures. G, intraoperative picture. The technique
of free margin plication is shown here. The photograph has been
rotated to orient the coronary cusps the same way as in the TEE ME
AV SAX view. H, ME AV SAX view. Midesophageal aortic valve short-axis
view shows the postoperative thickened aspect of both the cusp
plication performed at the free margin of the right coronary cusp and of
the 3 subcommissural annuloplasty sutures placed at the midlevel of
the intercommissural triangles. I, ME AV LAX view. Left, Midesophageal
aortic valve long-axis view shows a good leaflet coaptation. Right, Color
Doppler interrogation shows no residual aortic insufficiency. J, Deep TG
view. Deep transgastric view confirms good leaflet coaptation and
shows mild central residual aortic insufficiency. Ao ascending aorta;
LA left atrium; LAA left atrial appendage; LV left ventricle;
LVOT left ventricular outflow tract; Mi V mitral valve; NCC
noncoronary cusp; LCC left coronary cusp; RCC right coronary
cusp; PV pulmonary valve; RA right atrium; RV right ventricle.
Video Clip 7, association of type IA (ascending aorta dilation) and
type II (cusp prolapse) as coexisting mechanisms of aortic insufficiency, corrected by subcommissural annuloplasty, free margin
resuspension of the right coronary cusp, and replacement of the
aorta by a supracoronary tube graft. A, ME AV LAX view. Midesophageal aortic valve long-axis view shows a partial prolapse of the right
coronary cusp. The bending of the cusp and a thickened band are
clearly seen. B, ME AV LAX view. Left, Midesophageal aortic valve
long-axis view shows a partial prolapse of the right coronary cusp
with a thickened band and a resulting loss of coaptation. Right, Color
Doppler interrogation shows an eccentric aortic regurgitant jet
directed posteriorly toward the anterior mitral leaflet. C, ME AV SAX
view. Left, Midesophageal aortic valve short-axis view depicting the
fibrous band parallel to the free margin of the right coronary cusp
(sliding arrow). D, Still frame ME ascending aorta LAX view. The
aortic diameter approximately 4 cm above the aortic annulus is 4.4
cm. In this case it was decided to replace the ascending aorta
because of the fragility and poor quality of the aortic wall tissue. E,
Surgical repair. Surgery consisted of resuspension of the free margin
of the right coronary cusp (RCC) (intraoperative picture), 3 subcommissural annuloplasty sutures, and replacement of the ascending
aorta with a prosthetic tube graft starting from the sinotubular
junction. F, ME AV SAX view. In this postoperative midesophageal
aortic valve short-axis view, the thickened aspect of the commissures after the repair is well depicted. G, ME AV LAX view. In this
postoperative midesophageal aortic valve long-axis view, the thickened aspect of the aortic cusp after resuspension and the corrugated aspect of the prosthetic tube graft above the sinotubular
junction (STJ) are visualized. A thin mobile structure connecting the RCC
to the anterior STJ is sometimes seen, corresponding to the attachment
of the cusp to the commissure. H, Still frame. Midesophageal aortic
valve long-axis view shows excellent cusp coaptation after repair
(blinking yellow line). In this case, the length of coaptation is approximately 1 cm and extends from well above the plane of the aortic
annulus up to an imaginary line drawn at the midlevel of the sinuses of
Valsalva. Ao ascending aorta; LA left atrium; LV left ventricle;

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67

REVIEW ARTICLE

NCC noncoronary cusp; LCC left coronary cusp; RCC right

coronary cusp; RA right atrium; RV right ventricle.
Video Clip 8, association of type IB (root dilation) and type II
(cusp prolapse) as causes of aortic insufficiency in a bicuspid aortic
valve. A, ME AV SAX view. Left, Midesophageal aortic valve short-axis
view of a bicuspid aortic valve. A raphe is clearly seen (arrowhead)
along with a large oval structure corresponding to the short-axis
cross-section of the prolapsing leaflet (arrow). Right, Color flow
Doppler interrogation demonstrates a regurgitant jet along the whole
coaptation line. B, ME AV LAX view. Left, Midesophageal aortic valve
long-axis view showing dilation of the aortic root and systolic doming
of the valve opening. The sinotubular junction is effaced, the
coaptation length appears short, and the anterior cusp is mildly
prolapsing below the plane of the aortic annulus. Right, Color flow
Doppler demonstrates an eccentric regurgitant jet directed posteriorly, toward the anterior mitral leaflet, confirming a prolapse of the
anterior cusp. Ao ascending aorta; LA left atrium; LV left
ventricle; RA right atrium; RV right ventricle.
Video Clip 9, quadricuspid aortic valve repair by rendering the
valve tricuspid. A, ME AV SAX view. Left, Midesophageal aortic valve
short-axis view shows a quadricuspid aortic valve presenting with a
central defect of coaptation. Right, Color Doppler shows central
insufficiency. B, ME AV LAX view. Midesophageal aortic valve longaxis view with Color Doppler shows a slightly eccentric regurgitant jet
originating from the malcoapting cusps. C, Still image 1. Intraoperative appearance of the valve with 4 cusps as seen by the surgeon. D,
Surgical repair. The valve has been rendered tricuspid by suturing
the 2 smaller cusps (left coronary cusp [LCC] and fourth cusp). E,
Still image 2. Intraoperative aspect of the valve as seen by the
surgeon after the repair. The valve is now tricuspid with a reconstructed LCC. The suture line is visualized (arrow). F, ME AV SAX
view. Midesophageal aortic valve short-axis view showing the postrepair appearance of the valve. The suture line in the middle portion
of the LCC is seen (arrow). The presence of subcommissural
annuloplasty sutures explains the thickened aspect of 2 commissures. G, ME AV LAX view. Color Doppler imaging from the
midesophageal aortic valve long-axis view after tricuspidization.
Valve opening is good and only a trivial central aortic insufficiency is
seen. Ao ascending aorta; LA left atrium; LV left ventricle;
NCC noncoronary cusp; LCC left coronary cusp; RCC right
coronary cusp; fourth C fourth cusp; PA pulmonary artery; RA
right atrium; RV right ventricle.
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