Aortic valve repair for tri-leaflet aortic insufficiency associated with asymmetric aortic root aneurysms

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 for tri-leaflet aortic insufficiency associated with asymmetric aortic root aneurysms

Annals of Cardiothoracic Surgery ◽

10.21037/acs.2019.04.10 ◽

2019 ◽

Vol 8 (3) ◽

pp. 426-429 ◽

Cited By ~ 2

Author(s):

George T. Stavridis ◽

Richard S. Downey ◽

Marc W. Gerdisch ◽

G. Chad Hughes ◽

Marek J. Jasinski ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Root ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Valve Repair

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Bicuspid Aortic Valve Repair for Aortic Insufficiency Without Aortic Root Aneurysm: Does Preoperative Annular Diameter Matter for Long-term Durability?

Structural Heart ◽

10.1080/24748706.2019.1589259 ◽

2019 ◽

Vol 3 (sup1) ◽

pp. 65-65

Author(s):

Mary A. Siki

Keyword(s):

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Aortic Root ◽

Aortic Insufficiency ◽

Aortic Valve Repair ◽

Valve Repair ◽

Aortic Root Aneurysm

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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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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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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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