Early Outcomes of Patients Undergoing Neoaortic Valve Repair Incorporating Geometric Ring Annuloplasty

Abstract

Objectives During congenital heart surgery, the pulmonary valve and root may be placed into the systemic position, yielding a “neoaortic” valve. With the stress of systemic pressure, the pulmonary roots can dilate, creating aneurysms and/or neoaortic insufficiency (neoAI). This report analyzes the early outcomes of patients undergoing neoaortic valve repair incorporating geometric ring annuloplasty. Methods Twenty-one patients underwent intended repair at six centers and formed the study cohort. Thirteen had previous Ross procedures, five had arterial switch operations, and three Fontan physiology. Average age was 21.7 ± 12.8 years (mean ± SD), 80% were male, and 11 (55%) had symptomatic heart failure. Preoperative neoAI Grade was 3.1 ± 1.1, and annular diameter was 30.7 ± 6.5 mm. Results Valve repair was accomplished in 20/21, using geometric annuloplasty rings and leaflet plication (n = 13) and/or nodular release (n = 7). Fourteen had neoaortic aneurysm replacement (13 with root remodeling). Two underwent bicuspid valve repair. Six had pulmonary conduit changes, one insertion of an artificial Nodulus Arantius, and one resection of a subaortic membrane. Ring size averaged 21.9 ± 2.3 mm, and aortic clamp time was 171 ± 54 minutes. No operative mortality or major morbidity occurred, and postoperative hospitalization was 4.3 ± 1.4 days. At discharge, neoAI grade was 0.2 ± 0.4 ( P < .0001), and valve mean gradient was ≤20 mm Hg. At average 18.0 ± 9.1 months of follow-up, all patients were asymptomatic with stable valve function. Conclusions Neoaortic aneurysms and neoAI are occasionally seen late following Ross, arterial switch, or Fontan procedures. Neoaortic valve repair using geometric ring annuloplasty, leaflet reconstruction, and root remodeling provides a patient-specific approach with favorable early outcomes.

Evolution of techniques for repair of intermediate-type bicuspid aortic valves

“…His autograft was believed to be trileaflet, but on closer inspection, a small fusion was present at the top of 1 commissure, consistent with an IBAV defect—but of the pulmonary autograft. 17 The nonfused leaflet was 21 mm, but the other cusps were 19 mm. Because of nearly equal leaflet sizes, a trileaflet repair was chosen with a 19 mm trileaflet ring, again rotated 120°.…”

Use of aortic wall patches as leaflet replacement material during aortic valve repair

“… 6 AVr also is becoming more common for insufficient aortic valves. 7 , 8 , 9 , 10 , 11 , 12 When adequate native valve leaflets exist, the current success of AVr is excellent 13 ; however, in patients with defective leaflet tissue, prosthetic valve replacement still is required. Pericardial leaflet patches have been thoroughly tested, but have almost uniformly failed.…”

Invited Commentary: Some Thoughts on a New “Geometric Ring Annuloplasty” Device

“…Kupferschmid et al 1 report that the mean annular diameter had to be reduced from 30.7 to 21.9 millimeters (mm) to achieve a competent valve. For that reason, the use of the “geometric ring annuloplasty” (which fixes the LVOT at a relatively small diameter with a prosthetic device; ring size averaged 21.9 ± 2.3 mm) should not be advocated in younger patients, as this may lead to the eventual development of obstruction of the LVOT.…”

“…As the authors say, the outcomes of this newly designed "geometric ring annuloplasty" must be carefully followed in the coming years to define its advantages and possible disadvantages. 1…”

“…Kupferschmid et al 1 have reported their experience with “geometric ring annuloplasty” for neoaortic valve repair.…”