Aortic valve repair with a newly approved geometric annuloplasty ring in patients undergoing proximal aortic repair: early results from a single-centre experience

Abstract

OBJECTIVES Aortic insufficiency (AI) is common in patients with proximal aortic disease, but limited options exist to facilitate aortic valve repair (AVr) in this population. This study reports ‘real-world’ early results of AVr using newly FDA-approved trileaflet and bicuspid geometric annuloplasty rings for patients with AI undergoing proximal aortic repair (PAR) in a single referral centre. METHODS All patients undergoing AVr with a rigid internal geometric annuloplasty ring (n = 47) in conjunction with PAR (ascending +/− root +/− arch) were included. Thirty-six patients underwent AVr with a trileaflet ring, and 11 patients underwent AVr with a bicuspid ring. The rings were implanted in the subannular position, and concomitant leaflet repair was performed if required for cusp prolapse identified after ring placement. RESULTS The median age was 58 years [interquartile range (IQR) 46–70]. PAR included supracoronary ascending replacement in 26 (55%) patients and remodelling valve-sparing root replacement with selective sinus replacement in 20 (42%) patients. Arch replacement was performed in 38 (81%) patients, including hemi-arch in 34 patients and total arch in 4 patients. There was no 30-day/in-hospital mortality. Preoperative AI was 3–4+ in 37 (79%) patients. Forty-one (87%) patients had zero–trace AI on post-repair transoesophageal echocardiography, and 6 patients had 1+ AI. The median early post-repair mean gradient was 13 mmHg (IQR 5–20). Follow-up imaging was available in 32 (68%) patients at a median of 11 months (IQR 10–13) postsurgery. AI was ≤1+ in 97% of patients with 2+ AI in 1 patient. All patients were alive and free from aortic valve reintervention at last follow-up. CONCLUSIONS Early results with geometric rigid internal ring annuloplasty for AVr in patients undergoing PAR appear promising and allow a standardized approach to repair with annular diameter reduction and cusp plication when needed. Longer-term follow-up will be required to ensure the durability of the procedure.

A modern approach to aortic valve insufficiency: Aortic root restoration via HAART 300 internal annuloplasty ring

“…In‐hospital mortality was zero and postoperative morbidity rates were remarkably low 9 . Similar results were also extracted by the largest American series concerning HAART rings 1 . Among 47 patients who received the internal geometric annuloplasty ring along with ascending aorta/aortic root replacement, 30‐day/in‐hospital mortality was zero.…”

“…Among 32 patients whose imaging was available at last follow‐up, zero AI was detected in 47%, 1+ AI in 50% and 2+ AI in 3%. Interestingly, none of the eight patients, who received a valve sparing root replacement procedure along with HAART subannular implantation having less than 2+ preoperative AI, had more than 1+ AI at last follow‐up 1 . Another large, multicenter, European trial by Rankin et al 12 also reported promising results of internal geometric ring annuloplasty along with intervention in the proximal aorta.…”

“…HAART provides with an appropriate aortic root to facilitate AVr in patients with ascending aortic aneurysms. After HAART implantation and subsequent annular downsizing and ellipticality restoration, aortic leaflets are better approximated to the midline thus improving cusp coaptation 1,26 . Leaflet interventions such as leaflet shaving and plication to repair the valve can then be accurately performed achieving excellent leaflet vertical coaptation height and valve competence with low mean valve gradients 26 .…”

“…However, future technical experience with this novel approach could further improve outcomes 9 . The longterm durability of the procedure remains to be proven by longer‐term follow‐up 1 …”

Leaflet Dimensions as a Guide to Remodeling Annuloplasty During Aortic Valve Repair

“…The early clinical results of aortic ring annuloplasty as an adjunct to AVr have been presented elsewhere. 12,13,17 -20 At this point in time, approximately 1,000 rings have been implanted clinically for 40 different AI pathologies, with an AI repair rate exceeding 90%. 11 Long-term follow-up data are becoming available and demonstrate an 8-year Kaplan-Meier freedom from all-cause death and reoperation exceeding 80%, 21 consistent with other repair outcomes.…”