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

Abstract

Kupferschmid et al 1 have reported their experience with "geometric ring annuloplasty" for neoaortic valve repair.The ring annuloplasties were performed in 21 patients (from 6 centers) with an average age of 21 ± 12.8 years (range 11-62 years). All patients presented with a leaking neoaortic valve that originally was a pulmonary valve: after Ross procedure, arterial switch operation, or Fontan surgery. The geometric ring annuloplasty has been used previously to repair and stabilize "native" aortic valves. [2][3][4] Two types of annuloplasty rings were used, one for bicuspid and one for tricuspid valves. The rings were implanted directly under the valve. Associated procedures were leaflet plication, the release of Arantius nodule, insertion of an artificial Arantius nodulus, replacement of aneurysmatic neoaortic root, or selective replacement of a dilated sinus. In one patient with only mild insufficiency, a subaortic fibrous membrane with a mean left ventricular outflow tract (LVOT) gradient of 60 mmHg was resected.No mortality or important complications occurred. Valve insufficiency decreased significantly from grade 3.1 ± 1.1 to grade 0.2 ± 0.4 at discharge from hospital. In one patient condition of the leaflets made valve repair not possible. After an average follow-up of 18.0 ± 9.1 months, valve function remained stable and mean gradients were under 20 mmHg. In one patient with rheumatic valve disease, regurgitation had increased to grade 2. Short-term outcomes are thus encouraging.However, there are some questions and concerns for the future. It is not fully clear how much the use of the geometric annuloplasty ring contributed to the outcome as a variety of associated repair techniques was used concomitantly.In patients with a pulmonary valve in an aortic position, the goal of repair instead of replacement can also be obtained by using other techniques: in our own recent experience regurgitant, neoaortic valves associated with dilated roots could in some patients be repaired with David's reimplantation technique or with the more recently introduced Personalized Aortic Root Support (PEARS) technique. This has been reported by other groups. [5][6][7][8] These techniques also stabilize the valve annulus and have the advantage of avoiding a subvalvular ring that is placed in the bloodstream. While the reimplantation procedure involves the use of a vascular prosthesis, the PEARS technique has no foreign material in contact with the blood. 7,8 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. Another reason to be cautious in using this device is that these patients sooner or later will need another reoperation. It may be expected that t...