Korean J Radiol.  2020 Feb;21(2):181-191. 10.3348/kjr.2019.0446.

Preoperative Cardiac Computed Tomography Characteristics Associated with Recurrent Aortic Regurgitation after Aortic Valve Re-Implantation

• Ahn Y
• Koo HJ
• Lee S
• Kim DH
• Song JM
• Kang DH
• Song JK
• Kim HJ
• Kim JB
• Jung SH
• Choo SJ
• Chung CH
• Lee JW
• Kang JW
• Yang DH

• KMID: 2471635
• DOI: http://doi.org/10.3348/kjr.2019.0446

Abstract

OBJECTIVE
To identify the preoperative cardiac computed tomography (CT) factors influencing postoperative recurrent aortic regurgitation (AR) in patients who underwent aortic valve repair with the re-implantation technique (David operation) due to AR.
MATERIALS AND METHODS
A total of 117 patients (age, 49.4 ± 15.6 years; 83 males) who underwent the David operation for AR were included in this retrospective study. Aortic root profiles including the aortic regurgitant orifice area (ARO) and the aortic cusp asymmetry ratio of the areas (ASR(area)), which is defined as the maximum/minimum areas among the three cusp areas at the level of the commissures, were measured on preoperative cardiac CT scans. Clinical and CT findings were compared between a group with recurrent AR grade < 3 (no, trivial, or mild AR) and recurrent ≥ 3 + AR. To determine the optimal cut-off values of ASR and ARO, the receiver operating characteristic (ROC) curve was used. Cox regression analysis was used for the analysis of the factors affecting recurrent 3 + AR.
RESULTS
Postoperatively, recurrent 3 + AR developed in 17 (14.5%) patients and occurred within a median of 268 days (interquartile range: 78-582 days). The cut-off ARO value for discriminating the patients with recurrent 3 + AR was > 24 mm² (sensitivity, 76.5%; specificity 64.8%), and the area under the ROC curve (AUC) was 0.72. For ASR(area), the cut-off value was > 1.58 (sensitivity, 76.5%; specificity, 58.0%) and the AUC was 0.64. Multivariable Cox regression showed that ARO > 24 mm² (hazard ratio = 3.79, p = 0.020) was a potential independent parameter for recurrent 3 + AR. ROC for the linear regression model showed that the AUC for both ARO and ASR(area) was 0.73 (95% confidence interval, 0.64-0.81, p < 0.001).
CONCLUSION
ARO and ASR(area) detected on preoperative cardiac CT would be potentially helpful for identifying AR patients who may benefit from the David operation.

Keyword

Aortic valve; Aortic valve insufficiency; Computed tomography angiography; Echocardiography

MeSH Terms

Aortic Valve Insufficiency*
Aortic Valve*
Area Under Curve
Echocardiography
Humans
Linear Models
Retrospective Studies
ROC Curve
Sensitivity and Specificity
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Measurement of ARO. A. Schema of AR with prolapse of coronary cusp. B. Patient with prolapse of right coronary cusp causing AR. Levels of tips of cusps are not parallel to annulus level. En-face view of AV at level of C, dotted line in (A) and (B), is depicted in (C), and tip of right coronary cusp is not delineated on this level. At level of (D), right coronary cusp is noted, but ARO cannot be drawn below intercommissural points. (E) Using 10-mm thickness images (white box area) in en-face view, we can include tips of coronary cusps as depicted in figure (F), and ARO is drawn (dotted area) (G). All CT images are obtained on end-diastolic phase. AR = aortic regurgitation, ARO = aortic regurgitant orifice area, AV = aortic valve

• 

  Fig. 2 Measurement of aortic cusp ASR. A. Measurement of ARO (dashed white line) on AV en-face view when in end-diastolic phase. Cross-sectional image is acquired with 10-mm thick-slab overlapping. B. AV en-face view when in end-systolic phase at level comprising all three commissures. C. ASRdiameter was defined as maximum/minimum lengths among three diameters (dashed lines) from one commissure to tip of opposite cusp. D. ASRarea was defined as maximum/minimum areas among three cusp areas (dashed white lines). ASR = asymmetry ratio, ASRarea = aortic cusp asymmetry ratio of areas, ASRdiameter = aortic cusp asymmetry ratio of diameters, L = left coronary cusp, N = non-coronary cusp, R = right coronary cusp, RR = RR interval

• 

  Fig. 3 34-year-old female with type 1a AR. A, B. Aortic cusp ASRdiameter (dashed lines) and ASRarea (dashed white lines) were measured on end-systolic phase. C, D. ARO was measured on end-diastolic phase. (C) Leaflets are not well demonstrable on 1-mm thickness image of AV in en-face view; therefore, (D) 5–10-mm-thick slices are used to measure ARO (dashed white line). E. On postoperative CT, four days after David operation, AV en-face view on end-diastolic phase demonstrated small central coaptation defect (arrowheads). F. Recurrent ARO was noted on thick-slice thickness (dotted-lined area). On same day, grade 3 AR was detected.

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  Fig. 4 ROC curves for two cardiac CT predictive factors (ARO and aortic cusp ASRarea) for predicting recurrent 3 + AR after AV repair with re-implantation technique (David operation). AUC = area under ROC curve, CI = confidence interval, ROC = receiver operating characteristic

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  Fig. 5 Kaplan–Meier survival analysis of curves for absence of recurrent 3 + AR according to preoperative cardiac CT parameters (ARO [A] and aortic cusp ASRarea [B], respectively).

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