Rationale for aortic annuloplasty to standardise aortic valve repair

Abstract

Available evidence shows that aortic valve repair reduces valve-related mortality and improves quality of life compared to prosthetic aortic valve replacement. One of the most important predictors of bicuspid and tricuspid aortic valve repair failure is the absence of treating a dilated aortic annulus greater than 25-28 mm. Competency of the aortic valve depends on multiple factors including the diameter of the annulus, sinotubular junction, valve cusps and commissures. Dystrophic aortic insufficiency (AI) is the commonest cause of AI in the Western world and is characterised by dilatation of the aortic annulus (≥25 mm), sinuses and/or sinotubular junction (≥30 mm). Depending on whether the sinuses of Valsalva and/or tubular ascending aorta are dilated, three phenotypes can be identified: dilated aortic root, dilated ascending aorta and isolated AI. All three phenotypes are associated with a dilated aortic annulus. Aortic annuloplasty reduces the dilated aortic annulus and improves the surface of coaptation, as in the case of mitral valve repair. In treating AI, it is also important to restore the physiological sinotubular junction/annulus ratio, which can be carried out with remodeling root repair + subvalvular annuloplasty (for dilated aortic root), tubular ascending aorta replacement + subvalvular annuloplasty (for dilated ascending aorta) and double sub-and supra-valvular annuloplasty (for isolated AI). Aortic annuloplasty is now considered an essential component of aortic valve repair and valve-sparing root surgery.

Aortic Valve Repair Using Geometric Ring Annuloplasty

“…External annuloplasty can be performed with a Dacron band, similar to reimplantation. 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.…”

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

“…Deep external root dissection also is required. External annuloplasty can be performed with a Dacron ring, 4,25 usually reducing the annulus by one size. As shown in Figure 3, Figure 4, Figure 5, and Figure 6 -6, considerable variation exists in the degree of annular dilatation, so a one-size annular reduction seems less than precise.…”

Transcatheter Aortic Valve Replacement for Bicuspid Aortic Insufficiency After Valve-Sparing Aortic Root Replacement

“…Over the past years, a modified surgical technique offers BAV patients with root aneurysms to replace the dilated segment while preserving the valvular components ( 3 ). The VSARR was associated with lower surgical complications such as heart block and cerebral hemorrhage and had a higher survival rate than the traditional Bentall surgical procedure, which also uses replacement of the aortic valve ( 4 ).…”