Systematic evaluation of the AV after repair is mandatory. According to the American Society of Echocardiography  guidelines, the following steps in assessment of AV repair are recommended:

(1) A successfully repaired AV has no or minimal residual AR by interrogation with color flow Doppler.  The presence of greater than mild AR, especially if eccentric, should prompt further investigation to determine the mechanism of post-repair AR and help guide re-repair or possible valve replacement. The valve interrogation should take into account the type of repair. For example, excessive reduction in annular dimensions in a patient with a dilated aortic annulus and type I AR may result in excess leaflet tissue and subsequent type II AR due to cusp prolapse.

(2) The level of cusp coaptation should be at or above the aortic annulus in the ME AV LAX view. An effective height (distance from the aortic annulus to the leaflet tips)  greater than 9 mm is associated with a high probability of normal or near normal AV function. Conversely, in patients with cusp coaptation below the annular level, the risk of subsequent significant AR can be as high as 71%.

(3) The cusp coaptation height should be >4 mm as measured in the ME AV LAX view. The likelihood of moderate or severe AR at long-term follow-up is minimal when coaptation height is =4 mm, even when mild AR has been identified in the early postoperative exam.

(4) A large aortic annulus post-repair has also been associated with a high failure rate. It is recommended that the aortic annulus diameter post-repair should be less than 25 mm.

(5) The post-repair mean transvalvular pressure gradient should be less than 10 mm Hg.

Hence the correct answer is option ‘c’.

References

1. Nicoara A, Skubas N, Ad N, et al. Guidelines for the use of transesophageal echocardiography to assist with surgical decision-making in the operating room: A surgery-based approach: From the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. J Am Soc Echocardiogr 2020;33:692-734.
2. Munaf M, Babu S, Sukesan S, et al. Intraoperative transesophageal chocardiographic assessment of aortic valve repair in a child - What to look for? Ann Card Anaesth 2024;27:53-7.
3. Berrebi A, Monin JL, Lansac E. Systematic echocardiographic assessment of aortic regurgitation-what should the surgeon know for aortic valve repair? Ann Cardiothorac Surg 2019;8:331-41.