Reply to Bozok et al.

Abstract

We thank Bozok et al. for their comment on our results of aortic valve repair using an aortic ring [1–2]. Reoperation rate was 5.5% (8/144). Intraoperative findings at reoperation were cusp prolapse in all cases, without macroscopic lesions on cusp tissue. As other authors have, we showed that resuspension of cusp effective height should be performed intraoperatively in all cases of aortic valve repair [3–5], which was not the case for the eight reoperated patients in our study. Further analysis showed that ‘repair with gross visual estimation’ repair and absence of per operative effective height resuspension (using Schafers et al. [4] calliper) were an independent risk factor of reoperation and residual AI ≥grade II at follow up [5]. The systematic intraoperative resuspension of cusp effective height increased dramatically the rate of cusp repair (70.6 versus 20.3%, P < 0.001) and improved significantly the preliminary results since there was no reoperation or AI ≥grade II at 1-year follow-up [5]. Remodelling of the aortic root offers a physiological reconstruction of the root. Cusp motion and flow patterns across the reconstructed aortic root are more physiologic (i) after remodelling of the aortic root than after reimplantation of the aortic valve, and (2) after procedures using a prosthetic conduit fashioned with neo-sinuses of valsalva than without. However, contrarily to the reimplantation, the remodelling technique does not address the annular base dilation. Our physiological approach of aortic valve repair is based on reduction in dilated root diameters (aortic annular base through a subvalvular aortic annuloplasty ring and STJ through remodelling of the aortic root); respect of root dynamics (expansibility through the interleaflet triangles and restoration of sinuses of Valsalva) and restoration of cusp coaptation height (measurement of the effective height). In these series, a Dacron prototype of aortic ring was used. It allowed us to obtain a significant reduction in dilated aortic annular base diameter, without significant transvalvular aortic gradient. To address the need for a dedicated aortic annuloplasty device to facilitate technical standardization, we designed a new expansible aortic ring to achieve complete and calibrated annuloplasty in diastole, while maintaining the systolic expansibility of the aortic root [6]. As such, the cusp coaptation height is increased, reducing stress on the cusps and protecting the repair. A standardized and physiologic approach to aortic valve repair, considering both the aorta (root remodelling) and the valve (resuspension of the cusp effective height and subvalvular ring annuloplasty), improved the preliminary results and might affect their long-term durability.