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

Abstract

Objective In chronic aortic insufficiency (AI), the method and degree of annular downsizing required to achieve durable coaptation in aortic valve repair (AVr) remains poorly defined. This study evaluated the relationship between leaflet size and annular diameter to predict adequate annular sizing in remodeling AVr. Methods Under regulatory supervision, 74 patients with chronic tri-leaflet AI underwent AVr using ring annuloplasty and leaflet reconstruction. Fifty-four (73%) had ascending aortic ( n = 25) and/or root ( n = 29) aneurysms, and aortic grafts were sized 5 to 7 mm larger than the rings. Intraoperatively, leaflet free-edge length (FEL) was measured with special ball sizers positioned in the coronary sinus, and “normal” annular diameter was predicted from the validated formula: Required “normal” diameter = FEL/1.5. “Normal” annular diameters predicted from FEL were compared with pathologic diameters measured intraoperatively with Hegar dilators, and both were correlated with gender, age, and BSA. Results Average age was 62.1 ± 13.3 years (mean ± SD), 73% (54/74) were male, and 96% (71/74) had moderate-to-severe AI. All patients had annular dilatation, with a pathologic diameter 26.6 ± 2.3 mm before repair, and a predicted “normal” diameter of 21.7 ± 1.7 mm ( P < 0.001). Both predicted and pathologic annular diameters were larger in men ( P < 0.001), but no relationship existed with age. BSA correlated with both predicted and pathologic diameters, although variability was large. Conclusions Based on a simple validated method to predict “normal” annular diameter, all patients with chronic AI have some degree of annular dilatation. This finding implies that most AVr should include annuloplasty, with adequate and precise annular reduction based on leaflet size.

Early results of geometric ring annuloplasty for bicuspid aortic valve repair during aortic aneurysm surgery

“… 31 As with mitral and tricuspid valve insufficiency, most aortic valves with chronic AI exhibit annular dilatation. 32 Reduction in annular dimension to a value appropriate for leaflet size is an objective method of ring sizing and a significant advantage of this approach. 4 , 18 Moreover, remodeling BAV annular geometry to 180° commissures allows routine repair of valves with a variety of commissural orientations, such as intermediate-type BAV with 3 equal sinuses and unicuspid valves.…”

Aortic Valve Repair Using Geometric Ring Annuloplasty

“…42,43 With this approach, a band usually is chosen to reduce the annulus by one size. As shown previously, 14 considerable variation exists in the degree of annular dilatation, so a onesize annular reduction seems less than precise. Annuloplasty also can be performed by circumferential suture annuloplasty either internally or externally located.…”

“…39 With this approach, the Hegar-defined annular diameter usually is reduced to 23-25 mm, which again, may not be appropriate for all patients, and annuloplasty guided by leaflet size seems more objective. 14 Having the option of selecting either 2-or 3-leaflet reconstruction has significant utility for repairing more complex valve defects (Table 1), such as quadricuspid aortic valve. 44 Finally, availability of internal ring annuloplasty possibly could allow expansion of AVr from 25% to 30% of AI cases with existing techniques 7,8 to over 90%, as summarized in this report.…”

“…3A). For TAV patients with chronic AI, the pathologic annulus is almost always dilated, 14 and the ring diameter (D) required to optimize leaflet coaptation is determined from the formula: D = FEL/1.5. This concept is based on the observation in human cadaver valves 19 that annular diameter of the normal aortic valve is always similar to that of the leaflet-sinus complex, and that the leaflet FEL always subtends half of the leaflet-sinus circumference (hence the 1.5 value reflects p=2Þ: With this unique sizing approach facilitated by ball sizers, the annular dimensions required for appropriate coaptation are determined from the geometry of the aortic valve leaflets instead of the dilated annulus.…”

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

“…In previous analyses of adult aortic aneurysm patients, that number was 5 mm. 44 This difference, together with the high incidence of vibratory Nodular injury and scarring may reflect delayed surgical referral in the neoAI population. Perhaps a reproducible approach to AVr will facilitate earlier patient referral, as standardization of repair has in mitral regurgitation.…”