External Aortic Annuloplasty Research Articles

External aortic annuloplasty with a dedicated expansible ring improves outcomes in remodeling root repair compared with homemade Dacron ring

ObjectivesIn remodeling valve-sparing root replacement with external annuloplasty, we compare long-term outcomes of a calibrated expansible extra-aortic ring with a homemade Dacron ring. MethodsAll patients (2003-2020) operated for root aneurysm with/without aortic insufficiency (AI) were included. The standardized CAVIAAR (conservation aortique valvulaire dans les insuffisances aortiques et anévrysmes de la racine-Valve sparing in aortic insufficiencies and root aneurysms) technique was root remodeling and external annuloplasty ring with the EXTRA-AORTIC Ring or homemade Dacron ring. ResultsAmong 486 patients (age 52.3 ± 14.0 years) operated for root aneurysm, 375 (repair rate: 77.1%) underwent root remodeling with annuloplasty (extra-aortic ring, n = 289, vs Dacron ring, n = 86). At 10 years (median follow-up, 4.08 years’ interquartile range, 1.95-7.61), unmatched and matched analysis showed that patients with extra-aortic ring had greater survival, similar to the general population (93.3% vs 79.9%, P = .097), lower reoperation incidence (2.0% vs 9.7%, P = .0098), and lower AI grade >2 recurrence (1.9% vs 11.2%, P = .0042), compared with patients with a Dacron ring. Mixed-effect model showed that with extra-aortic ring annuloplasty, annular dilation over time (P = .0033) was prevented and, compared with the homemade Dacron ring, root expansibility was better preserved (3.22% vs 2.12%, P = .002) and mean transvalvular gradient was lower (6.58 mm Hg vs 7.94 mm Hg, P = .001). Tricuspid and bicuspid valves with extra-aortic ring had similar reoperation (4.3% vs 0.85%, P = .65) and AI grade >2 incidence (2.7% vs 1.2%, P = .61), expansibility (P = .29), and diameter (P = .47), whereas mean transvalvular gradient was lower for tricuspid valves (5.58 mm Hg vs 7.60 mm Hg, P = .004). ConclusionsValve-sparing root remodeling with calibrated expansible extra-aortic ring annuloplasty improves the outcomes of reoperation and recurrent AI compared with a homemade Dacron ring. It prevents dilation and maintains physiological root dynamics for durable valve repair.

Aortic root remodeling with external annuloplasty for acute type A aortic dissection: Midterm results.

To evaluate the role of aortic root remodeling with external aortic annuloplasty (ARREAA) in acute type A aortic dissection (AAAD). From May 2011 to May 2020, 59 patients out of 240 with AAAD underwent ARREAA. Data were retrospectively collected and analyzed. The mean age was 61.4 ± 8.6 years and 43 patients were males (73%). Hemiarch and total arch replacement were performed in 37 (62.7%) and 14 (23.7%) patients. An aortic valvuloplasty was performed in seven patients (11.8%). Five patients (8.5%) required coronary artery bypass graft. Re-exploration for bleeding was required in six patients (10.1%). The 30-day mortality rate was 18.6%. Preoperative hemodynamic instability (odds ratio [OR] = 8.57, 95% confidence interval [CI] = 1.57-46.71; p = 0.013), consciousness disorder (OR = 19.18, 95% CI = 3.02-121.72]; p = 0.002) or myocardial ischemia (OR = 6.28, 95% CI = 1.27-31.10; p = 0.013) were significantly associated with postoperative mortality. No patient was reoperated for aortic valve during the postoperative period. One patient suffered a stroke postoperatively with partial recovery. Kidney failure requiring temporary dialysis occurred in 12 patients (20.3%). At discharge, a transthoracic echocardiogram showed moderate aortic regurgitation (AR; grade 2) in two patients. During follow-up (mean = 58.4 ± 32.4 months), three patients died. The rate of mortality was 6.2%. Actuarial survival at 5 years was 76.3%. No patient required reoperation on the proximal aorta or aortic valve. At 4 years, freedom from any aortic valve or root reintervention and AR > 2 were both 100%. In a center with expertise in valve-sparing procedures, ARREAA is a reasonable option in the surgical management of AAAD in selected patients. This technique stabilizes the aortic annulus and preserves root anatomy for durable outcomes.

Isolated aortic insufficiency valve repair with external ring annuloplasty: a standardized approach.

Aortic valve (AV) insufficiency with normal root and ascending aorta is most frequently treated by valve replacement with significant prosthetic-related complications and reduced life expectancy. We compared the outcomes of a new standardized isolated AV repair approach using an external aortic annuloplasty ring at the subvalvular level (single ring annuloplasty) and the role of an additional supravalvular ring at the sinotubular junction (double ring annuloplasty). Single centre data were collected from the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) between 2003 and 2017. A total of 93 patients (56 single ring and 37 double ring) underwent isolated AV repair. The overall 30-day mortality rate and the need for a permanent pacemaker were 1% and 2%, respectively. The overall survival rate at 6 years was similar for sex- and age-matched members of the general population (89% vs 95%; P = 0.1) and did not differ between the double and single ring groups (82% vs 93%; P = 0.4) at 6 years. There were no thromboembolic or bleeding events in the entire cohort. However, at 6 years, the cumulative incidence of valve-related reintervention was 26% in the single ring annuloplasty group compared to 3% in the double ring annuloplasty (P = 0.02) group. Similarly, at 6 years, the cumulative incidence of moderate-to-severe (>2) aortic insufficiency was 30% in the single ring annuloplasty group compared to 0% in the double ring annuloplasty group (P = 0.007). Standardized AV repair with external ring annuloplasty has a survival rate similar to that of the general population. The additional stabilization of the sinotubular junction with a second supravalvular ring (double ring annuloplasty) is associated with better outcomes compared to single subvalvular annuloplasty. It can be considered as a first line intervention for patients with isolated aortic insufficiency and pliable leaflets.

Invited Commentary

Invited Commentary

Surgical Anatomy of the Aortic Annulus: Landmarks for External Annuloplasty in Aortic Valve Repair

Although reduction of a dilated aortic annulus is becoming an essential parameter for durablevalve repair, anatomical descriptions of the annulus and surgical landmarks of the subvalvular planefor an external aortic annuloplasty remain to be defined. Twenty hearts with normal anatomy with tricuspid aortic valves were studied. Annulus diameter, cusp geometric height, and interleaflet triangles heightswere measured. The aortic root was dissected externally down to the subvalvular plane as to perform an external aortic annuloplasty or reimplantation procedure proximal anastomosis. Tissue thickness and dissection heights relative to the annulus were measured at each cusp nadir and at the middle of each interleaflet triangle. The mean annulus diameter, cusp geometric height, and interleaflet triangle heights were, respectively, 24.9 ± 0.2 mm, 19.7 ± 0.3 mm, and 20.1 ± 0.5 mm. External dissection of the aortic root reached thesubvalvular plane below the nadir of left coronary cusp (-2.7 ± 0.4 mm), noncoronary (NC) cusp (-3.1 ± 0.3 mm), and the base of left-NC interleaflet triangle (-2.1 ± 0.4 mm). External dissection remained above the nadir of the right coronary cusp (+1.4 ± 0.4 mm), base of left-right interleaflet triangle (+2.4 ± 0.6 mm), and right-NC interleaflet triangle (+3.4 ± 0.3 mm). Mean tissue thickness between the inner and external side of the subvalvular plane was 2.5 ± 0.1 mm. External dissection of the aortic annulus allows subvalvular placement of an external aortic ring below the left and NC cusps and below or within 3 mm of the right cusp nadir in 80% of cases. An external aortic annuloplasty would induce at least a 5-mm reduction of annulus diameter, corresponding to tissue thickness. Precise anatomical landmarks are important to standardize aortic valve annuloplasty.

Remodeling of the aortic root combined to an expansible aortic ring annuloplasty

Aortic root aneurysms are characterized by dilation of both functional aortic annulus diameters (aortic annular base and sino-tubular junction), preventing coaptation of otherwise pliable valves often associated with cusp prolapse. Multiple techniques of aortic valve sparing procedures try to restore the complex interplay of aortic valve and root function in order to improve durability of the repair. Ideally, procedures should treat dilatation of the aortic annular base, while preserving dynamics of the aortic root with vortices (neosinuses of Valsalva) and root expansibility (interleaflet triangles). We describe a standardized approach, combining the advantages of both the remodeling and reimplantation technique by adding an external subvalvular ring annuloplasty to the physiological remodeling of the aortic root. To address the need for a dedicated aortic annuloplasty device, a new expansible aortic ring was designed in order to achieve a complete and calibrated annuloplasty in diastole, while maintaining systolic expansibility of the aortic root.

An expansible aortic ring for a physiological approach to conservative aortic valve surgery

Dystrophic aortic insufficiency is characterized by dilation of the aortic annular base and sinotubular junction diameters preventing coaptation of thin and pliable cusps amenable to valve repair. An expansible aortic ring was designed to reduce dilated aortic root diameters to increase valvular coaptation height while maintaining root dynamics. The properties of the device were tested in vitro and in vivo in an ovine model. Expansible rings were composed of an elastomer core covered by polyester fabric. After in vitro analysis of their mechanical properties, the rings were implanted in 6 sheep at both the level of the annular base and sinotubular junction (double subvalvular and supravalvular external aortic annuloplasty). Root dynamics were assessed by using intracardiac ultrasonography before surgical intervention and at 6 months. Histologic, scanning electron microscopic, and mechanical studies were then performed on explanted samples. The expansible ring produced a significant reduction of the aortic annular base and sinotubular junction diameters. Coaptation height was increased from 2.5 +/- 0.7 mm to 6.2 +/- 1.1 mm (P < .001). Mechanical testing on 6-month explanted samples revealed no significant differences in elastic modulus. Dynamics of the root were well preserved. Histomorphologic studies showed incorporation of the material without degradation. Expansible aortic ring implantation produces a significant annuloplasty that increases coaptation height while preserving the dynamics of the aortic root. The effectiveness of the device in treating aortic insufficiency is currently being evaluated in the prospective Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root trial comparing conservative aortic valve surgery versus mechanical valve replacement.