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

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.

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Quadricuspid Aortic Valve Repair Facilitated by Geometric Ring Annuloplasty

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/15569845211003095 ◽

2021 ◽

pp. 155698452110030

Author(s):

Joseph A. McGuire ◽

Heather K. Hayanga ◽

Jeremiah W. Hayanga ◽

Daniel Sloyer ◽

Matthew Ellison ◽

...

Keyword(s):

Aortic Valve ◽

Patient Outcomes ◽

Systematic Approach ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Autologous Reconstruction ◽

Quadricuspid Aortic Valve ◽

Valve Repair ◽

Ring Annuloplasty ◽

Annular Geometry

Quadricuspid aortic valve (QAV) is a rare congenital anomaly often associated with aortic insufficiency. The exact anatomy of QAV is variable, and most cases have undergone aortic valve replacement. With the recognition that aortic valve repair achieves superior patient outcomes as compared to replacement, a systematic approach to autologous reconstruction of QAV is needed. This article reports 2 cases having successful repair utilizing geometric aortic annuloplasty rings, and describes a proposed scheme for repairing most QAV defects, based on relative leaflet and commissural characteristics. Using either tri-leaflet or bicuspid ring annuloplasty, the normal sub-commissural triangles can be remodeled into a 120° or 180° configuration, respectively, and then the leaflets can be sutured and plicated to fit annular geometry. With this approach, most quadricuspid valves potentially could undergo autologous reconstruction.

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Techniques of Aortic Valve Repair

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e31824641d7 ◽

2011 ◽

Vol 6 (6) ◽

pp. 348-354 ◽

Cited By ~ 10

Author(s):

J. Scott Rankin ◽

Jeffrey G. Gaca

Keyword(s):

Aortic Valve ◽

Aortic Root ◽

Free Edge ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Valve Repair ◽

Aortic Valves ◽

Mitral Repair ◽

Cavitron Ultrasonic Surgical Aspirator ◽

Valve Reconstruction

Similar to mitral repair, newer methods of aortic valve reconstruction are achieving excellent outcomes with an 85% to 90% freedom from valve-related complications at 10 years. The goal of this review is to illustrate these newer and more stable techniques of aortic valve repair. Most patients with aortic insufficiency from either trileaflet or bicuspid aortic valves are candidates for repair, in addition to selected patients with mixed aortic stenosis/insufficiency and aortic root aneurysms. Initially, aggressive commissural annuloplasty is performed to reduce measured valve diameter to 19 to 21 mm. Leaflet prolapse is corrected with plication stitches placed in the free edge of each leaflet adjacent to the Nodulus Arantius. In this regard, the leaflet free edge functions as the chorda tendinea of the aortic valve, and shortening with plication stitches raises the leaflet to a proper “effective height.” Leaflet defects are augmented with gluteraldehyde-fixed autologous pericardium, and mild-to-moderate strategically placed spicules of calcium are removed with the cavitron ultrasonic surgical aspirator. Using these methods, most insufficient aortic valves, and many with mixed lesions, can be satisfactorily repaired. Six cases are illustrated in this review, spanning the spectrum of pathologies from annular dilatation without leaflet defects, to standard congenital bicuspid valve with prolapse, to trileaflet prolapse, to unusual bicuspid pathology with calcification, to a moderately calcified trileaflet valve with mixed lesions, and to aortic root aneurysms with severe aortic insufficiency. All valves were repaired using the techniques described above with trivial residual leak and minimal gradients. All repairs have been followed with yearly echocardiography, and valve reconstruction with these methods is now quite stable with excellent late outcomes. Most insufficient aortic valves now can undergo stable repair with minimal late valve-related complications. Greater application of aortic valve repair seems indicated.

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Geometric Ring Annuloplasty for Aortic Valve Repair during Aortic Aneurysm Surgery

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000539 ◽

2018 ◽

Vol 13 (4) ◽

pp. 248-253 ◽

Cited By ~ 16

Author(s):

J. Scott Rankin ◽

Domenico Mazzitelli ◽

Theodor Fischlein ◽

Yeong-Hoon Choi ◽

Jan Pirk ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Aneurysm ◽

Valve Replacement ◽

Aortic Root ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Aneurysm Surgery ◽

Valve Repair ◽

Ring Annuloplasty ◽

Aortic Aneurysm Surgery

Objective An aortic annuloplasty ring could be useful for aortic valve repair. This trial evaluated intermediate-term outcomes of internal geometric ring annuloplasty for repair of trileaflet and bicuspid aortic insufficiency associated with ascending aortic and/or aortic root aneurysms. Methods Under regulatory supervision, 47 patients with aortic insufficiency and ascending aortic (n = 22) and/or aortic root (n = 25) aneurysms were managed with aortic valve repair and aneurysm resection. Valve repair was performed using trileaflet (n = 40) or bicuspid (n = 7) internal geometric rings, together with leaflet reconstruction. Ascending aortic and/or remodeling root replacements were accomplished with Dacron grafts 5 to 7 mm larger than the rings. An Echo Core Lab provided independent echocardiographic assessments, and changes over time were evaluated by Friedman tests. Results Mean ± SD age was 60 ± 14 years, 57% (27/47) were male, 15% (7/47) had bicuspid valves, 87% (41/47) had moderate-to-severe aortic insufficiency, and 13% (6/47) had mild aortic insufficiency. All patients had annular dilatation, with a mean ± SD of 26.5 ± 2.6 mm before repair, and mean ± SD ring sizes were 21.7 ± 1.7 mm. Follow-up was 42 months (mean = 27 months). No operative mortality or valve-related complications occurred. Two patients died beyond 1 year from nonvalve-related causes. One patient required valve replacement for repair failure. Survival free of complications or valve replacement was 94% at 2 years. Significant reduction in aortic insufficiency and New York Heart Association class were observed ( P < 0.0001), and valve gradients remained low. No heart block or direct ring complications occurred. Conclusions In preliminary regulatory studies, aortic ring annuloplasty seemed safe and effective during aortic aneurysm surgery. This approach could help standardize aortic valve repair.

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Aortic Valve Repair in Annular Dilatation: External Versus Internal Suture Annuloplasty

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2021.06.021 ◽

2021 ◽

Author(s):

Theresa Holst ◽

Johannes Petersen ◽

Christoph Sinning ◽

Hermann Reichenspurner ◽

Evaldas Girdauskas

Keyword(s):

Aortic Valve ◽

Aortic Valve Repair ◽

Valve Repair ◽

Annular Dilatation

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Predictors of Recurrent Aortic Insufficiency in Type I Bicuspid Aortic Valve Repair

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2018.06.026 ◽

2018 ◽

Vol 106 (5) ◽

pp. 1316-1324 ◽

Cited By ~ 9

Author(s):

Andreas Habertheuer ◽

Rita Karianna Milewski ◽

Joseph E. Bavaria ◽

Mary Siki ◽

Melanie Freas ◽

...

Keyword(s):

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Type I ◽

Valve Repair

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A Regulated Trial of Bicuspid Aortic Valve Repair Supported by Geometric Ring Annuloplasty

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2015.01.050 ◽

2015 ◽

Vol 99 (6) ◽

pp. 2010-2016 ◽

Cited By ~ 23

Author(s):

Domenico Mazzitelli ◽

Steffen Pfeiffer ◽

J. Scott Rankin ◽

Theodor Fischlein ◽

Yeong-Hoon Choi ◽

...

Keyword(s):

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Aortic Valve Repair ◽

Valve Repair ◽

Ring Annuloplasty

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

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa009 ◽

2020 ◽

Vol 57 (6) ◽

pp. 1137-1144

Author(s):

Oliver K Jawitz ◽

Vignesh Raman ◽

Jatin Anand ◽

Muath Bishawi ◽

Soraya L Voigt ◽

...

Keyword(s):

Aortic Valve ◽

Transoesophageal Echocardiography ◽

Aortic Disease ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Valve Repair ◽

Annuloplasty Ring ◽

Aortic Repair ◽

Early Results

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.

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Aortic valve repair techniques: an early UK experience

Open Heart ◽

10.1136/openhrt-2019-001107 ◽

2019 ◽

Vol 6 (2) ◽

pp. e001107 ◽

Cited By ~ 1

Author(s):

Renata Greco ◽

Mirko Muretti ◽

Xy Jin ◽

Mario Petrou

Keyword(s):

Aortic Valve ◽

Free Edge ◽

Connective Tissue Disorder ◽

Aortic Valve Repair ◽

Valve Repair ◽

Sinotubular Junction ◽

Early Results ◽

The Uk ◽

Repair Techniques

ObjectivesRetrospective review of early results with aortic valve repair (AVr) techniques.Methods61 consecutive patients underwent AVr surgery at our institutions between 2008 and 2018. 14 patients had a bicuspid aortic valve and 16 had a connective tissue disorder. In 48 patients, aortic regurgitation (AR) was secondary to an aortic root and/or ascending aneurysms, while in 13 it was due to primary cusp pathologies. 13 patients underwent isolated cusp repair, 19 sinotubular junction remodelling, 25 valve-sparing root replacement (VSRR) and 4 hemiroot replacement. Cusp repair techniques included: 18 free margin plication, 18 commissural re-suspensions, 3 raphe resections and 1 free-edge reinforcement. Subcommissural annuloplasty was performed in 25 patients (42%) with a dilated annulus (>28 mm).Results50 patients (82%) left the operating theatre with no AR, 8 with mild central and 3 with mild eccentric AR. In-hospital survival was 100%. Clinical follow-up was complete at 5.08±2.29 years and all patients were alive. Transthoracic echocardiographic follow-up was complete at 2.35±1.92 years and showed the presence of a moderate AR in 10 patients (18%) and severe AR in 2 patients (4%). One of these required re-do aortic valve replacement 6 years after VSRR. Freedom from re-operation at 8 years was 88.15%±1.51%.ConclusionGood early results are achievable following AVr with acceptable medium-term outcomes. AVr surgery continues to evolve, and concentrating the experience in specialist centres in the UK is recommended.

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