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Original research
Aortic cusp abnormalities in patients with trileaflet aortic valve and root aneurysm
  1. Tristan Ehrlich1,
  2. Andreas Hagendorff2,
  3. Karen Abeln1,
  4. Lennart Froede1,
  5. Christian Giebels1,
  6. Hans-Joachim Schäfers1
  1. 1Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
  2. 2Cardiology, Leipzig University Medical Center, Leipzig, Germany
  1. Correspondence to Dr Hans-Joachim Schäfers, Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany 66421; h-j.schaefers{at}


Background The frequency of concomitant cusp pathology in aortic root aneurysm with or without aortic regurgitation is not well known, and the sensitivity and specificity of two-dimensional trans-oesophageal echocardiography (2D TEE) in its detection has not yet been specified.

Objectives We analysed the type and frequency of concomitant cusp alterations in root aneurysm referred for surgery. Sensitivity and specificity of 2D TEE in detecting these alterations were determined.

Methods In 582 patients (age 56.8±15.4 years, 453 male) with trileaflet aortic valves undergoing root replacement for regurgitation (n=347) or aneurysm (n=235), details of valve morphology were analysed. In a subcohort (n=281), intraoperative TEEs were analysed retrospectively and correlated with the intraoperative findings.

Results Any cusp pathology was present in 90.9% (prolapse: n=473; retraction: n=30; calcification: n=14; fenestration: n=12), morphologically normal cusps were seen in only 52 patients (8.93%). Valve-sparing surgery was performed in 525 (90.2%) instances, composite replacement in 57 (9.8%). Preoperative TEE correctly identified any postroot repair prolapse in 70.6% and any retraction in 85%. The sensitivity of TEE in detecting any prolapse was 68.6% (specificity of 79.5%). The sensitivity was highest for the right cusp and intermediate for the non-coronary.

Conclusions Cusp prolapse is frequent in root aneurysm and trileaflet aortic valves. Prolapse is underdiagnosed by 2D TEE in many cases because pre-existent stretching of cusp tissue is masked by the geometric effects of root dilatation.

  • aneurysm, dissecting
  • aortic aneurysm
  • diagnostic imaging
  • echocardiography
  • aortic valve insufficiency

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Correction notice This article has been corrected since it was published Online First. Typographical errors in the title and in author name Hans-Joachim Schäfers have now been fixed.

  • Contributors H-JS is responsible for the overall content as guarantor. TE and AH interpreted the results and drafted the manuscript. KA, LF and CG participated in data collection, interpreted the results and drafted the manuscript. TE, KA and LF extracted the data and performed the statistical analyses. AH created all the figures. All the authors participated in data collection and provided a critical review of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.