Aortic annuloplasty: Subcommissural, intra-annular suture techniques, external and internal rings

Abstract

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.

Commentary: Aortic annuloplasty: One size does not fit all

“…The accompanying review paper by Professor Scha¨fers' group nicely summarizes the concepts behind aortic valve annuloplasty. 1 The techniques include (1) subcommissural annular plication; (2) suture annuloplasty; (3) internal rings; (4) external rings or bands; and (5) reimplantation of the aortic valve. Of note, the first 3 options do not require deep circumferential dissection externally down to the basal ring.…”

Commentary: Aortic valve reconstruction: Embrace it and master it … for your patients' sake … and your future

“…Although there are multiple subtle technical differences among the different publications in the literature, there are fundamental concepts, which when adhered to, allow for a more standardized approach and a more durable outcome than ever before. 3 , 4 , 5 , 6 In general, if there is adequate surface area and quality of valve leaflet tissue, and one uses precise preoperative imaging and intraoperative assessment and current reconstructive techniques, a competent/nonobstructive valve with very reasonable durability can be obtained. From a patient's perspective, the opportunity to retain one's own tissue, whose biologic behavior far exceeds that of any other biologic substitute at this time, will be much preferred if durability can be achieved.…”

Aortic Valve Repair: The Evolving Frontiers of Aortic Annuloplasty

“…[1][2][3][4][5][6] The options for aortic annuloplasty have received considerable attention recently due to their importance for durability of aortic valve repair. 7,8 These annuloplasty options include a variety of suture techniques, as well as internal and external rings. [1][2][3][4][5][6][7] In this issue of the Journal, Tabrizi et al reported their clinical experience with an internal annuloplasty ring with ellipsoid geometry, with a focus on the perioperative and echocardiographic considerations.…”