Aortic Valve Repair Surgery Research Articles

Comparison of preoperative aortic valve imaging techniques for patients with aortic insufficiency undergoing aortic valve repair surgery

ObjectiveTo report the accuracy of preoperative 4-dimensinal cardiac computed tomography angiogram (CTA), real-time 3-dimensional transesophageal echocardiography (TEE) and intraoperative techniques in aortic valve (AV) measurement and phenotype determination in patients undergoing surgery for aortic insufficiency and/or root aneurysm. MethodsThis is a prospective, observational study of preoperative AV imaging for AV repair surgery. Twenty-two patients were accrued over 12 months. Preoperative TEE and CTA were obtained and measurements provided by dedicated imaging cardiologists. Intraoperative measurements were obtained from the arrested heart and reported by the surgeon before repair. Intraoperative assessment was considered the gold standard of height measurements, with CTA being the standard assessment for commissural orientation. Correlation coefficients were used to describe agreement of measurements. ResultsBaseline characteristics and assessment of phenotype and measurement of commissural orientation, geometric height and commissural heights are reported. TEE (κ = 0.833; P < .01) and CTA (κ = 0.729; P < .01) both agreed with intraoperative assessment of AV phenotype. TEE appeared more accurate than intraoperative measurement at predicting commissural orientation (rs = 0.79; P < .01 vs rs = 0.58; P = .01). CTA and TEE were unlikely to predict and measured shorter than intraoperative geometric height measurement. Measurements of commissural heights by CTA did not agree with and were shorter than intraoperative measurement. ConclusionsTEE and CTA both appear accurate in predicting the AV phenotype identified intraoperatively. CTA and TEE predicted shorter heights than intraoperative measurement.

Aortic valve repair surgery: a historical review, current analysis, and future prospects

Aortic valve repair surgery is an ancient surgical approach. It is ancient in the sense that it emerged alongside aortic valve replacement surgery, but was gradually abandoned due to suboptimal outcomes. Currently, aortic valve replacement surgery has become the preferred method for treating patients with aortic valve dysfunction, with or without aortic root lesions. However, due to the risks of prosthetic valve deterioration and anticoagulation-related complications, aortic valve repair surgery has re-emerged as an attractive treatment option, avoiding the long-term risks associated with prosthetic valves. However, it comes with the risk of recurrence of valve regurgitation. Remodeling and reimplantation are milestones in aortic valve repair, reducing the risk of aortic regurgitation. The concept of functional anatomy of the aortic root and the mechanism of aortic regurgitation lay the theoretical foundation for modern aortic valve repair. Aortic valve repair has become a comprehensive repair strategy that involves the basal ring, sinus, sino-tubular junction, and aortic lobes. The long-term survival rate is close to that of the normal population, and the valvular-related reintervention rate is comparable to that of valve replacement. Aortic valve repair is gradually becoming a novel alternative treatment for patients with aortic valve insufficiency, with or without aortic root lesions.

Segmental analysis of aortic basal ring dimensions in normal and dilated tricuspid aortic roots.

In patients with aortic root aneurysm, the aortic basal ring is frequently dilated. It has been speculated that the muscular part of the basal ring dilates most. The purpose of this study was to analyse the segmental dilatation of the basal ring, comparing normal and dilated roots in patients with tricuspid aortic valves. Retrospective analysis of computed tomography studies in patients with normal and dilated aortic roots was performed. Lengths of segments of the basal ring corresponding to each of the 3 sinuses, and to the muscular and fibrous parts were measured. Fractions of these segments relative to the total basal ring perimeter were calculated. We analysed 152 normal and 126 dilated aortic roots and 86 propensity-matched pairs. Basal ring dilatation was present in all segments of dilated aortic roots with subtle differences between the segments corresponding to the 3 sinuses. The muscular part of the basal ring dilated proportionately to its fibrous part, with no difference in fractions of measured muscular part in normal and dilated roots [42.2% (interquartile range 4.3%) vs 42.1% (interquartile range 6.3%)]. Basal ring dilatation was present in all segments corresponding to the 3 sinuses in dilated aortic roots. Both muscular and fibrous parts dilated equally, supporting the need to stabilize the entire basal ring when performing aortic valve repair surgery.

The effect of postoperative intravenous iron in anaemic, older cardiac surgery patients on disability-free survival (AGE ANEMIA study): study protocol for a multi-centre, double-blind, randomized, placebo-controlled trial

BackgroundPostoperative anaemia is common in older cardiac surgery patients and often caused by iron deficiency. Anaemia may negatively affect recovery after cardiac surgery. This study aims to determine the efficacy of treatment of postoperative iron deficiency anaemia (IDA) with intravenous iron (IVI) on disability 90 days after cardiac surgery in older patients.MethodsThis is a randomized placebo-controlled double-blind multi-centre trial. In total, 310 patients aged ≥ 70 years with moderate IDA on postoperative day 1 (haemoglobin 85–110 g/L and ferritin concentration < 100 μg/L or iron saturation < 20%) after uncomplicated elective cardiac surgery (aortic valve repair or coronary artery bypass graft surgery) will be included. Patients will be randomly allocated to receive either IVI (ferric derisomaltose) or placebo (sodium chloride 0.9%) on postoperative day 1 in a 1:1 ratio, stratified by centre and type of cardiac surgery. The primary outcome is disability measured by the 12-item World Health Organization Disability Assessment score 2.0 after 90 days. Secondary outcome measures are the number of postoperative red blood cell (RBC) transfusions, change in reticulocyte haemoglobin content (pg) from randomization to hospital discharge, Hb levels at discharge, hospital complications, dyspnoea (assessed with the Rose Dyspnoea Scale) and health-related quality of life (HRQL) (assessed with The Older Persons and Informal Caregivers-Short Form (TOPICS-SF) questionnaire) after 90 days and days alive and out of hospital after 90 days. Lastly, the functional outcomes (e.g. steep ramp or 6-min walk test) and Hb level after 90 days will be assessed as an exploratory endpoint.DiscussionThe results of this study will demonstrate whether early treatment of postoperative IDA with IVI improves disability at 90 days in older cardiac surgery patients.Trial registrationClinicalTrials.gov NCT04913649. Registered on June 4, 2021.

Permanent pacemaker implantation after valve and arrhythmia surgery in patients with preoperative atrial fibrillation.

Among patients referred for cardiac surgery, atrial fibrillation (AF) is a common comorbidity and a risk factor for postoperative arrhythmias (eg, sinus node dysfunction, atrioventricular heart block), including those requiring permanent pacemaker (PPM) implantation. The purpose of this study was to evaluate the prevalence and long-term survival of postoperative PPM implantation in patients with preoperative AF who underwent valve surgery with or without concomitant procedures. Presented analysis pertains to the HEIST (HEart surgery In atrial fibrillation and Supraventricular Tachycardia) registry. During the study period, 11,949 patients underwent valvular (aortic, mitral, or tricuspid valve replacement or repair) surgery and/or surgical ablation (SA) and were stratified according to postoperative PPM status. PPM implantation after surgery was necessary in 2.5% of patients, with significant variation depending on the type of surgery (from 1.1% in mitral valve repair to 3.3% in combined mitral and tricuspid valve surgery). In a multivariate logistic regression model, tricuspid intervention (P <.001), cardiopulmonary bypass time (P = .024), and endocarditis (P = .014) were shown to be risk factors for PPM. Over long-term follow-up, PPM was not associated with increased mortality compared to no PPM (hazard ratio 0.96; 95% confidence interval 0.77-1.19; P = .679). SA was not associated with PPM implantation. However, SA improved survival regardless of PPM status (log rank P <.001). In patients with preoperative AF, the need for PPM implantation after valve surgery or SA is not an infrequent outcome, with SA not affecting its prevalence but actually improving long-term survival.

Outcomes of aortic valve repair: early results from the German Aortic Valve Registry.

Aortic valve (AV) repair is an evolving surgical strategy in the treatment of young patients with aortic regurgitation (AR) and/or aortic root aneurysm. We aimed to determine the clinical outcome following AV repair/AV-sparing root surgery using real-world data from the German Aortic Valve Registry. A total of 2327 patients with AR (mean age 55.2 ± 15.0 years, 76% men), who underwent AV repair/AV-sparing root surgery between 2011 and 2015 (i.e. 5% of 42868 AV surgery patients enrolled in the German Aortic Valve Registry during the same period) were included. Study cohort was subdivided according to the technique of AV repair: isolated AV repair without root surgery (group I) (n = 914), AV-sparing root surgery (i.e. reimplantation or remodelling) without cusp repair (group II) (n = 1077) and AV-sparing root surgery (i.e. reimplantation or remodelling) with simultaneous cusp repair (group III) (n = 336). Primary end point was 1-year survival after AV repair/AV-sparing root surgery. Secondary end points were freedom from cardiac adverse events and freedom from AV reinterventions at 1-year follow-up. Thirty-day mortality was 19 (0.8%) in the whole study cohort without significant differences in the 3 subgroups [4 (0.4%) patients in group I vs 14 (1.3%) patients in group II vs 1 (0.3%) patient in group III (P = 0.054)]. Postoperatively, 1445 (74%) patients had no residual AR, 474 (24%) patients had mild AR and 40 (2%) patients had moderate/severe AR at the time of hospital discharge. One-year survival (95% confidence interval) was 97.7% (97.1-98.3) in the whole study cohort and without significant difference among the 3 subgroups. One-year cardiac adverse event-free survival (95% confidence interval) was 85.7% (84.2-87.1) and was similar in all 3 study groups in propensity score-weighted analysis. A total of 38 (1.6%) patients required AV reintervention during a 1-year follow-up, without significant difference among subgroups (P = 0.11). AV repair/AV-sparing root surgery is performed in 5% of patients requiring AV surgery in Germany. Our data demonstrate very satisfactory periprocedural and 1-year survival and cardiac event-free survival after AV repair surgery. Implementation of specific surgical techniques during the index procedure seems to result in comparable outcomes.

Abstract 11610: Characteristics and Predictors of Effective Height of the Aortic Valve Assessed by Electrocardiography-Gated Cardiac Computed Tomography

Introduction: Effective height of the aortic valve has been used as an index for durable aortic valve repair. This study aimed to analyze the relationship between effective height and the other morphological parameters of aortic valve complex when aortic valve is closed. Methods: We retrospectively analyzed 100 patients (70.7±10.2 years) without diseased aortic valve, root or ascending aorta, who had electrocardiography-gated cardiac computed tomography as a screening test of coronary artery, from August 2014 to December 2018. Parameters of the configuration of aortic valve complex (effective height ; geometric height ; aortic annular diameter ; sinus of Valsalva diameter ; sinotubular junction diameter ; commissure height) in diastole were measured using the software Ziostation2 (Ziosoft, Tokyo, Japan). Pearson correlation was used to evaluate the association between effective height and the other parameters. In addition, multiple regression analysis was performed to determine which variables predict effective height. Results: Significant correlations were shown between effective height and geometric height (r = 0.704 ; P &lt; 0.001), sinus of Valsalva diameter (r = 0.433 ; P &lt; 0.001), sinotubular junction diameter (r = 0.547 ; P &lt; 0.001) and commissure height (r = 0.396 ; P &lt; 0.001). There was no significant correlation between effective height and aortic annular diameter (r = 0.111 ; P = 0.27). Multivariable analysis showed that geometric height (regression coefficients β = 0.853 ; 95% confidence intervals, CI, 0.647 to 0.923 ; P &lt; 0.001), aortic annular diameter (β = -0.574 ; 95% CI, -0.467 to -0.284 ; P &lt; 0.001) and sinotubular junction diameter (β = 0.327 ; 95% CI, 0.085 to 0.211 ; p &lt; 0.001) were significant predictors of effective height. The overall model fit was R 2 = 0.716. Conclusions: This study demonstrated that effective height was strongly correlated with geometric height, and predicted by geometric height, aortic annular diameter and sinotubular junction diameter. These findings may help heart surgeon to decide an appropriate effective height for individual aortic valve complex during aortic valve repair surgery.

Late results of aortic valve repair for isolated severe aortic regurgitation.

The objectives were to analyze the long-term outcomes of tricuspid aortic valve repair for isolated severe aortic regurgitation and the impact of different annuloplasty techniques. The study cohort consists of 127 consecutive patients who received aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve between 1996 and 2019 in our institution. Exclusion criteria were aorta dilatation (≥45mm), connective tissue disease, active endocarditis, type A dissection, and rheumatic disease. Mean age of patients was 55.6±16years, and 80% were male. Median follow-up was 6.4years. Time-to-event analysis was performed, as well as risk of death, reoperation, and aortic regurgitation recurrence. Cusp repair was performed in 117 patients (92%), and annuloplasty was performed in 126 patients (99%) with Cabrol stitch (73%), reimplantation technique (19.7%), or ring annuloplasty (6.3%). There was no hospital mortality. At 10 and 14years, overall survival was 81%±5% and 71%±6%, respectively, and freedom from reoperation was 80%±5% and 73%±6%, respectively. Age and left coronary cusp repair were independent predictors of reoperation. Freedom from recurrent severe aortic regurgitation (>2+) was 73%±5% and 66%±7% at 10 and 12years, respectively. Age, left ventricular end-diastolic diameter, and patch repair were independent predictors of recurrent aortic regurgitation. Type of annuloplasty had no impact on survival or reoperation. Aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve is a safe procedure, and durability at 14years is acceptable. In this study, the annuloplasty technique did not influence repair durability as was found in bicuspid aortic valve repair or aortic valve-sparing surgery. Severity of cusp pathology seems to be the main determinant of repair durability.

Early and Late-Term Follow-Up Results of Patients Diagnosed with Aortic Aneurysm or Aortic Dissection with Aortic Regurgitation Undergoing Aortic Valve Repair or Valve-Sparing Aortic Surgery.

IntroductionValve-reimplantation and remodelling techniques used in aortic reconstruction provide successful early, mid, and long-term results. We present our early and late-term experience with 110 patients with aortic regurgitation (AR) who underwent aortic valve repair (AVr) or valve-sparing aortic root surgeries (VSARS) due to aortic dissection or aortic aneurysm.MethodsNine hundred eighty-two patients who underwent aneurysm or dissection surgery and aortic valve surgery between April 1997 and January 2017 were analysed using the patient database. A total of 110 patients with AR who underwent AVr or VSARS due to aortic dissection or aortic aneurysm were included in the study.ResultsIn the postoperative period, a decrease was observed in AR compared to the preoperative period (P<0.001); there was an increase in postoperative ejection fraction (EF) compared to the preoperative values (P<0.005) and a significant decrease in postoperative left ventricle diameters compared to the preoperative values (P<0.001). Kaplan-Meier analysis revealed one, two, four, and five-year freedom from moderate-severe AR as 95%, 91%, 87%, and 70%, respectively. Freedom from reoperation in one, two, and five years were 97.9%, 93.6%, and 81%, respectively. Eight patients (7.4%) underwent AVr during follow-up. Out of the remaining 100 patients, 13 (12%) had minimum AR, 52 (48%) had 1st-2nd degree AR, and 35 (32%) had 2nd-3rd degree AR during follow-up.ConclusionFor the purpose of maintaining the native valve tissue, preserving the EF and the left ventricular end-diastolic diameter, valve-sparing surgeries should be preferred for appropriate patients.

Preoperative left ventricular end-systolic dimension predicts occurrence of aortic insufficiency following aortic valve preservation and repair surgery

BackgroundPreoperative left ventricular (LV) end-systolic dimension (LVESD) ≥5.0 cm is a class IIa indication for surgical intervention for aortic insufficiency (AI); however, the effect of LV dilatation on the longevity of the aortic valve (AV) has not yet been investigated. This study aimed to assess the impact of preoperative LV dimension on the long-term outcome of AV preservation surgery. MethodsBetween 2009 and 2019, 256 patients underwent AV preservation surgery at a single center. The median duration of follow-up was 5 years. The primary outcome was the development of >1+ AI at 6 years; secondary outcomes include long-term mortality, freedom from >2+ AI, and freedom from AV reoperation. Cox proportional hazard analysis was performed to identify predictors of AV deterioration. ResultsIn-hospital mortality was 0.8%, and mean survival at 8 years was 85.5 ± 3.4%. Mean freedom from >1+ AI at 6 years was 71.1 ± 3.4%. Patients with preoperative indexed LVESD (LVESDi) ≥2.0 cm/m2 were at greater risk of developing >1+ AI at 6 years compared with patients with preoperative LVESDi of 1.5 to 1.9 cm/m2 and ≤1.4 cm/m2 (50.3 ± 0.1% vs 80.9 ± 0.1% vs 92.2 ± 0.1%, respectively; P < .01). On risk-adjusted multivariable analysis, preoperative LVESDi was an independent predictor for recurrence of >1+ AI (hazard ratio, 2.2; 95% confidence interval, 1.5-3.4). ConclusionsPreoperative LVESDi ≥2 cm/m2 is associated with increased risk of recurrent >1+ AI following AV preservation surgery. Further investigation of the appropriate operative threshold for AI may be warranted.

Valve Thrombosis Or Hypo-attenuating Leaflet Thickening After Tavr And Savr: Is There A Need For Different Therapeutic Strategies?

Introduction: Transcatheter aortic valve repair (TAVR) and conventional cardiac surgery with valve replacement using sutureless bioprostheses are possible options to treat severe symptomatic aortic valve stenosis. No definite guidelines exist regarding the postinterventional anticoagulation therapy especially in patients with atrial fibrillation.

Aortic Valve Repair Compared to Replacement: Starting an Aortic Valve Repair program, is it Worthwhile?

Objective: There is increasing evidence that aortic valve repair surgery leads to better long-term outcomes than valve replacement, although these data mainly come from a few specialized centers an...

Aortic valve repair: An evolving space in cardiac surgery

The surgical management of pure aortic regurgitation (AR) continues to evolve and the choice of operation depends on several factors including, the patho-anatomy of the aortic valve and root, patient characteristics and surgical expertise. The absence of an ideal biological or mechanical prosthesis historically stimulated the development of innovative valve-conserving techniques. Early pioneers invented the now established valve sparing aortic root replacement using the remodelling and re-implantation techniques [1,2] which focus on the geometrical correction of the aortic root and restoration of the normal alignment of the aortic valve apparatus to eliminate secondary AR. In the last 10 years or so however, some surgeons have pushed the envelope even further by introducing novel approaches to address primary AR using cusp repair techniques and associated annuloplasty [3-5]. This concept is analogous to more established mitral valve repair techniques which are now refined, reproducible and associated with excellent clinical outcomes. Indeed, it could be said that the current status of aortic valve repair surgery stands where mitral valve repair was some 35 years ago i.e. the preserve of only a hand-full of surgeons working in high-volume centres with a strong innovative ethos.

Aortic Root Pressurizing Device: Aortic Valve Evaluation During Cardioplegic Arrest

The aortic root pressurizing device was developed for aortic valve repair surgery. It allows echocardiographic evaluation of the aortic valve during cardioplegic arrest by mimicking diastolic afterload. This polyoxymethylene or polyether ether ketone-based device consists of a sealing cap nut, a sealing ring, a plug screw, and both a filling and a ventilation line. It can be easily connected to any size of aortic Dacron grafts. The device was tested in 15 porcine hearts using a beating heart biosimulator including hemodynamic and echocardiographic monitoring. Valve competence was analyzed on both the beating and resting heart at 60 and 45 mm Hg root pressure. Aortic insufficiency was surgically induced by leaflet manipulation. Native aortic valves showed either none or trivial aortic insufficiency. After leaflet manipulation echocardiographic proof of valve insufficiency was possible in all specimen. Jet direction was identic in all cases at 60 mm Hg and 93% at 45 mm Hg root pressure. The aortic root pressurizing device shows highly comparable results of echocardiographic aortic valve evaluation between static and dynamic settings under experimental conditions.

Aortic valve repair techniques: an early UK experience

ObjectivesRetrospective review of early results with aortic valve repair (AVr) techniques.Methods61 consecutive patients underwent AVr surgery at our institutions between 2008 and 2018. 14 patients had a bicuspid aortic valve...

Aortic valve repair: state of the art

Mechanical or bioprosthetic aortic valve replacement has traditionally been the treatment of choice for patients with aortic valve insufficiency. However, prosthetic valve replacement has significant limitations being associated with a substantial cumulative risk of thromboembolism, anticoagulation-related hemorrhage, prosthetic valve endocarditis, and structural or non-structural valve dysfunction requiring reoperation. In this setting, aortic valve repair, by avoiding the long-term risks associated with prosthetic valve implantation, has emerged as a valid alternative treatment to conventional aortic valve replacement. In the last decade, improvements in the understanding of the mechanisms of valve disease, development of a classification system for aortic insufficiency and advances in surgical procedures have allowed for more effective and reproducible techniques for aortic valve repair. The aim of the present review is to assess the principles, the surgical techniques, and the role of echocardiographic imaging in the setting of aortic valve repair surgery.

Corrigendum to 'Free margin length and geometric height in aortic root dilatation and leaflet prolapse: implications for aortic valve repair surgery' [Eur J Cardiothoracic Surg 2020;57:124-132

Corrigendum to 'Free margin length and geometric height in aortic root dilatation and leaflet prolapse: implications for aortic valve repair surgery' [Eur J Cardiothoracic Surg 2020;57:124-132

Clinical and Echocardiographic Outcomes After Aortic Valve Repair Surgery.

To assess early and late clinical outcomes in patients who underwent aortic valve repair surgery for aortic valve insufficiency, and to investigate predictors for recurrence. Of 151 consecutive patients who underwent aortic valve repair surgery for varying degrees of aortic insufficiency (AI) in our department between 2004 and 2018, 60 (40%) underwent aortic root replacement, 71 (47%) aortic cusp plication, 31 (20%) subcommissural annuloplasty, 29 (19%) circular annuloplasty, and 28 (18%) autologous pericardial patch augmentation. One patient died in the hospital (0.7%). Mean clinical and echocardiographic follow-up was 62±43 months (range 1 to 159) and 50 ± 40 months (range 1 to 158), respectively. The overall survival rate was 99.3% at 1 year and 98% at 5 years of follow-up. Seventeen patients (11.3%) had recurrent severe AI, and all of them underwent reoperation with a mean duration to reoperation of 35 ± 39 months. Risk factors for the development of recurrent significant AI (≥3) or reoperation, by univariable analysis, were unicuspid or bicuspid aortic valve (AV) (P = 0.018), the use of subcommissural annuloplasty (P = 0.010), the need for cusp repair (P = 0.001), and the use of pericardial patch augmentation (P < 0.001). By multivariable analysis only the use of pericardial patch augmentation emerged as a significant independent predictor for the development of recurrent significant AI (≥3) or reoperation (P = 0.020). AV repair can be performed with low morbidity and mortality, with good early and late clinical outcomes. However, in our experience there was a significant rate of recurrent AI especially in patients who underwent cusp augmentation using glutaraldehyde-treated autologous pericardial patch.

Free margin length and geometric height in aortic root dilatation and leaflet prolapse: implications for aortic valve repair surgery.

Our goal was to assess the aortic leaflet free margin length (FML) and geometric height (gH) in a normal aortic valve (AV), aorta dilatation and aortic leaflet prolapse. We measured the FML and gH intraoperatively in 132 patients operated on for aortic insufficiency, aortic dilatation, endocarditis or fibroelastoma. Patients were divided into 3 groups: normal tricuspid AV (group 1, n = 12), aortic dilatation (group 2, tricuspid = 43, bicuspid = 18) and leaflet prolapse (group 3, tricuspid = 32, bicuspid = 27). The FML and gH were compared between the groups and between the leaflets within each group. In a normal tricuspid AV, the mean FML and gH were 34.7 ± 3.1 mm and 18.8 ± 1.7 mm, respectively. In group 2 tricuspid, the FML and gH were greater than those in group 1 (FML 43.7 ± 4.4, P < 0.001; gH 21.2 ± 1.8, P = 0.003). In group 3, tricuspid, the FML of the prolapsing leaflet was greater than the FML of the non-prolapsing leaflet (48.3 ± 5.4 vs 42.2 ± 3.6; P < 0.001). In group 2, bicuspid, FML of both leaflets were similar in group 2, but augmented on the fused leaflet compared to the non-fused leaflet in group 3 (fused 55.4 ± 6.3; non-fused 46.2 ± 6.2; P < 0.001). In groups 2 and 3 bicuspid, the gH of the non-fused leaflet was systematically greater than the fused leaflet (group 2 non-fused 24.6 ± 2.5 vs fused 20.4 ± 2.1; P < 0.001). In aortic dilatation and leaflet prolapse, FML and, to a lesser extent, gH increased significantly compared to those of normal AV function. FML and gH dimensions also depended on the valve configuration (tricuspid/bicuspid). These data provide new insight into the pathomorphology of AV disease and will serve to further develop new methods of AV repair based on intraoperative measurements of the FML.

Rationale for aortic annuloplasty to standardise aortic valve repair.

Available evidence shows that aortic valve repair reduces valve-related mortality and improves quality of life compared to prosthetic aortic valve replacement. One of the most important predictors of bicuspid and tricuspid aortic valve repair failure is the absence of treating a dilated aortic annulus greater than 25-28 mm. Competency of the aortic valve depends on multiple factors including the diameter of the annulus, sinotubular junction, valve cusps and commissures. Dystrophic aortic insufficiency (AI) is the commonest cause of AI in the Western world and is characterised by dilatation of the aortic annulus (≥25 mm), sinuses and/or sinotubular junction (≥30 mm). Depending on whether the sinuses of Valsalva and/or tubular ascending aorta are dilated, three phenotypes can be identified: dilated aortic root, dilated ascending aorta and isolated AI. All three phenotypes are associated with a dilated aortic annulus. Aortic annuloplasty reduces the dilated aortic annulus and improves the surface of coaptation, as in the case of mitral valve repair. In treating AI, it is also important to restore the physiological sinotubular junction/annulus ratio, which can be carried out with remodeling root repair + subvalvular annuloplasty (for dilated aortic root), tubular ascending aorta replacement + subvalvular annuloplasty (for dilated ascending aorta) and double sub- and supra-valvular annuloplasty (for isolated AI). Aortic annuloplasty is now considered an essential component of aortic valve repair and valve-sparing root surgery.