Aortic valve repair and valve-preserving root replacement have evolved into increasingly practiced procedures. With increasing experience, the need for an annuloplasty has become more evident, at least for pathologies that involve annular dilatation. To understand the effect of an aortic annuloplasty, it is necessary to know the details of aortic valve and root anatomy. Geometrically, the functional annulus is best defined as the virtual basal ring, ie, plane of the cusp nadirs. The sinotubular diameter also influences the aortic valve form, at least in tricuspid valves. Different annuloplasty concepts have been developed for isolated valve repair or in combination with root remodeling, such as subcommissural sutures, suture annuloplasty, external, and internal rings. Subcommissural sutures do not consistently provide durable annular stabilization. More positive results have been published for circular approaches, ie, suture annuloplasty, external, or internal rings. The results of different techniques are difficult to judge because most outcome data have not been analyzed with control of confounding predictors of repair failure. The evidence that annuloplasty improves aortic valve function and repair durability is best documented for isolated bicuspid aortic valve repair. In summary, the addition of annuloplasty to aortic valve reconstruction is probably a useful tool to improve valve competence and stabilize the repair. This is best documented for isolated bicuspid valve repair and circular approaches. The relative benefit of individual concepts is difficult to judge because of lack of both control groups and control of confounding factors. (JTCVS Techniques 2021;7:98-102) Sinotubular junction Cusp free margin Crown-like cusp insertion line gH Virtual basal ring eH Determinants of aortic valve and root geometry. gH, Geometric height; eH, effective height.

Background Bicuspid aortic valves (BAVs) predispose to ascending aortic aneurysm. Turbulent blood flow and genetic factors have been proposed as underlying mechanisms. Endothelial nitric oxide synthase (eNOS) has been implicated in BAV aortopathy, and its expression is regulated by wall shear stress. We hypothesized that if turbulent flow induces aneurysm formation in patients with a BAV, regional differences in eNOS expression would be observed in BAVs. Methods and Results Ascending aortic specimens were harvested intraoperatively from 48 patients with tricuspid aortic valve (19 dilated, 29 nondilated) and 38 with BAV (28 dilated, 10 nondilated) undergoing cardiac surgery. eNOS mRNA and protein concentration were analyzed at the convex and concave aortic wall. In nondilated aortas, eNOS mRNA and protein concentration were decreased in BAV compared with tricuspid aortic valve (all P <0.05). eNOS expression was increased in association with dilation in BAV aortas ( P =0.03), but not in tricuspid aortic valve aortas ( P =0.63). There were no regional differences in eNOS mRNA or protein concentration in BAV aortas (all P >0.05). However, eNOS expression was increased at the concave wall (versus convexity) in tricuspid aortic valve dilated aortas (all P <0.05). Conclusions Dysregulated eNOS occurs independent of dilation in BAV aortas, suggesting a potential role for aberrantly regulated eNOS expression in the development of BAV‐associated aneurysms. The absence of regional variations of eNOS expression suggests that eNOS dysregulation in BAV aortas is the result of underlying genetic factors associated with BAV disease, rather than changes stimulated by hemodynamic alterations. These findings provide insight into the underlying mechanisms of aortic dilation in patients with a BAV.

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Objective: The probability of aortic complications in patients with bicuspid aortic valve is higher in association with aortic regurgitation (AR) compared with aortic stenosis (AS) or normally functioning valves. The objective of this study was to determine whether this is related to the specific characteristics of aneurysmatic dilatation that includes AR or whether AR itself has a negative impact on the aortic wall, independent of aneurysmatic dilatation. Approach and Results: Nondilated aortic specimens were harvested intraoperatively from individuals with tricuspid aortic valves and either AS (n=10) or AR (n=16). For controls, nondilated aortas were harvested during autopsies from individuals with tricuspid aortic valves and no evidence of aortic valve disease (n=10). Histological and immunohistochemical analyses revealed that compared with control aortas, overall medial degeneration was more severe in AR-aortas ( P =0.005) but not AS-aortas ( P =0.23). This pathological remodeling included mucoid extracellular matrix accumulation ( P =0.005), elastin loss ( P =0.003), elastin fragmentation ( P =0.008), and decreased expression of fibrillin ( P =0.003) and collagen ( P =0.008). Furthermore, endothelial nitric oxide synthase expression was decreased in the intima ( P =0.0008) and in vasa vasorum ( P =0.004) of AR-aortas but not AS-aortas (all P >0.05). Likewise, subendothelial apoptosis was increased in AR-aortas ( P =0.03) but not AS-aortas ( P =0.50). Conclusions: AR has a negative effect on the nondilated ascending aortic wall. Accordingly, our results support the need for more detailed studies of the aortic wall in relation to aortic valve disease and may ultimately lead to more aggressive clinical monitoring and/or surgical criteria for patients with relevant AR.

We report a case in whom aortic wrapping had been performed for aortic dilatation. Ten years later, further progression of aortic root diameter was documented (root size of 66 mm). We performed complete replacement of the proximal aorta. Macroscopically and microscopically, there was extreme degeneration and thinning of the aorta under the graft.