Aortic Valve Repair Using Geometric Ring Annuloplasty

Abstract

Reparative operations for insufficient cardiac valves constitute the surgical procedures of choice when pathoanatomies permit. At present, mitral and tricuspid repair techniques are well-established, but recent data also suggest that reconstruction of insufficient aortic valves may be associated with lower operative mortality, fewer valve-related complications, and improved survival. In an effort to increase adoption of aortic valve repair and to mitigate recurrent insufficiency, annuloplasty rings based on normal aortic root geometry have been developed to position in the inflow portion of the aortic annulus similar to mitral and tricuspid rings. This review will describe techniques for tri-leaflet and bicuspid geometric ring annuloplasty, and also will address leaflet reconstruction methods for the common leaflet pathologies. The application of a pathoanatomic approach to aortic insufficiency now permits the majority of aortic valves to be repaired with acceptable clinical outcomes.

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

“…12,13,17 -20 At this point in time, approximately 1,000 rings have been implanted clinically for 40 different AI pathologies, with an AI repair rate exceeding 90%. 11 Long-term follow-up data are becoming available and demonstrate an 8-year Kaplan-Meier freedom from all-cause death and reoperation exceeding 80%, 21 consistent with other repair outcomes. With aneurysmal disease, a graft size of 5 to 7 mm larger than ring diameter recreates normal root geometry, 6,15 and ring annuloplasty allows root remodeling with application of selective sinus replacement when appropriate.…”

“…The technique for predicting normal annular diameter from leaflet FEL was developed in normal human cadaver aortic valves and has provided a consistent method for objectively reducing annular size to appropriate levels for full leaflet competence. 11 The term aortic “annulus,” as used in this paper, refers to the diameter of the valve base when deformed intraoperatively into a circle with a Hegar dilator, and in patients with chronic AI, this pathologic annular diameter was consistently enlarged, as compared to what would be predicted from leaflet size (Fig. 3).…”

“…This seems to be a fundamental property of aortic valve geometry and has been used to reliably predict required annuloplasty ring diameter in approximately 1,000 patients. 11 During AVr procedures in this series, tri-leaflet ring D required for valve competence was determined using a similar ball sizer positioned in each coronary sinus (Fig. 2).…”

Minimally invasive aortic valve repair using geometric ring annuloplasty

“…The addition of ring annuloplasty to MiAVr simplifies and standardizes the procedure, obviating the need for deep external root dissection or other complex maneuvers. This approach could allow more uniform MiAVr, perhaps to most AI etiologies and anatomies encountered, 15 including the full variety of proximal aortic replacements. One problem with previous AVr methods was strict patient selection, with only 27% of AI cases selected for repair in several series 22,23 .…”

“…Given the inferior results observed after aortic valve replacement, 5 strict selections and low repair rates could limit overall patient outcomes. One advantage of AVr with ring annuloplasty is that more than 40 AI etiologies have been repaired in over 1200 patients, with AI repair rates of 90%–95% 15 . Therefore, from the viewpoints of increasing Mi applications and augmenting repair rates, MiAVr with geometric ring annuloplasty could improve overall patient results, and reduce the risk of prosthetic valve complications over the long term.…”