A standardized and physiologic approach to aortic valve repair, considering both the aorta (root remodeling) and the valve (resuspension of the cusp effective height and subvalvular ring annuloplasty) improved the preliminary results and might affect their long-term durability. The ongoing Conservative Aortic Valve Surgery for Aortic Insufficiency and Aneurysm of the Aortic Root (CAVIAAR) trial will compare this strategy to mechanical valve replacement.

A new standardized approach to valve repair, combining an expansible aortic annuloplasty ring with the remodeling technique, presented similar 30-day results to mechanical CVG with a trend toward reducing major adverse valve-related events. Analysis of late outcomes is in process for 3- and 10-year follow-ups.

Implantation of an external aortic ring provides a reproducible technique for aortic valve repair with satisfactory preliminary results. The ongoing CAVIAAR trial (Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root) will compare this standardised repair technique using an expansible aortic ring to mechanical valve replacement.

Experience with repair of isolated aortic insufficiency (AI) is increasing, encouraged by the results of valve-sparing procedures. Current techniques associate the treatment of cusp prolapse with the reduction of the almost constantly dilated aortic annular base diameter. Although few series provided satisfying mid-term results in selected patients, the lack of standardization limits their widespread use. We developed a standardized aortic valve repair procedure for isolated AI (sinuses of Valsalva ≪40 mm), combining cusp repair with a subvalvular external aortic ring annuloplasty. Alignment of cusp free edges and resuspension of the cusp effective height are performed prior to implantation of the external subvalvular ring. The prosthetic ring is of an open configuration to allow its placement externally to the aorta and below the coronary arteries without detaching them from the aortic wall. Ring size is undersized by one size relative to annular base inner diameter measured intraoperatively. The aim of the ring is to reduce the dilated aortic annular base diameter while increasing coaptation height.

Aims Despite growing evidence that aortic valve repair improves long-term patient outcomes and quality of life, aortic valves are mostly replaced. We evaluate the effect of aortic valve repair versus replacement in patients with dystrophic aortic root aneurysm up to 4 years. Methods The multicentric CAVIAAR prospective cohort study enrolled 261 patients: 130 underwent standardized aortic valve repair (REPAIR) consisting of remodelling root repair with expansible aortic ring annuloplasty, and 131 received mechanical composite valve and graft replacement (REPLACE). Primary outcome was a composite criterion of mortality, reoperation, thromboembolic or major bleeding events, endocarditis or operating site infections, pacemaker implantation and heart failure, analyzed with propensity score-weighted Cox model analysis. Secondary outcomes included Major Adverse Valve Related Events (MAVRE) and components of primary outcome. Results Mean age was 56.1 years, valve was bicuspid in 115 patients (44.7%). Up to 4 years, REPAIR did not significantly differ from REPLACE in terms of primary outcome (HR 0.66 [0.39; 1.12]), but showed significantly less valve-related deaths (HR 0.09 [0.02; 0.34]) and major bleeding events (HR 0.37 [0.16; 0.85]) without an increased risk of valve-related reoperation (HR 2.10 [0.64; 6.96]). When accounting for occurrence of multiple events in a single patient, REPAIR group had half the occurrence of MAVRE (RR 0.51 [0.31; 0.86]). Conclusion Although primary outcome did not significantly differ between REPAIR and REPLACE group, the trend is in favour of REPAIR by a significant reduction of valve-related deaths and major bleeding events. Long-term follow-up beyond 4 years is needed to confirm these findings.