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MMCTS (March 29, 2007). doi:10.1510/mmcts.2006.001958
Copyright © 2007 European Association for Cardio-thoracic Surgery

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Procedure


Aortic annuloplasty: towards a standardized approach of conservative aortic valve surgery1,2,3

Emmanuel Lansaca,*, Isabelle Di Centab, François Raouxc, Richard Raffoula, Nawwar Al Attara, Akthar Ramad, Christophe Acard and Patrick Natafa

a Department of Cardiovascular Surgery, Bichat University Hospital, Assistance Publique Hôpitaux de Paris (APHP), 46 Boulevard de l'Hôpital, 75018 Paris, France
b Department of Vascular Surgery, Ambroise Paré University Hospital (APHP), Boulogne-Billancourt, France
c Department of Cardiology, Saint Antoine University Hospital (APHP), Paris, France
d Department of Cardiovascular and Thoracic Surgery, Pitié Salpêtriére University Hospital (APHP), Paris, France

* Corresponding author: * Tel.: +33-1-40-256702; fax: +33-1-40-256700. Email: emmanuel.lansac{at}bch.aphp.fr.


   Summary
Top
 Summary
Introduction
 Surgical techniques
 Results
 Discussion
 References
 
Dystrophy represents the most common etiology of aortic insufficiency and aortic root aneurysms in Western countries. Main characteristic lesions of dystrophic aortic roots are the constant dilation of the aortic annular base and sinotubular junction diameters, preventing coaptation of otherwise pliable bicuspid or tricuspid valves. Although these lesions are amenable to conservative aortic valve surgery, mechanical valve replacement remains the surgical standard. The multiplicity of current surgical techniques for conservative aortic valve repair substantiates the need for standardization. Analysis of the literature emphasizes two basic surgical objectives: the treatment of the lesions (dilation of aortic annular base and sinotubular junction) as well as the preservation of aortic root dynamics. From these findings, we suggest a standardized approach for conservative aortic valve surgery meeting both of these principles, based on the implantation of an expansible aortic ring. In the case of aortic root aneurysm, the remodeling technique is combined with a subvalvular external aortic annuloplasty. In the case of isolated aortic insufficiency, a double aortic annuloplasty (sub- and supravalvular) is performed.

Key Words: Aortic valve insufficiency • Aortic annuloplasty • Aortic root aneurysm • Aortic valve repair • Bicuspid valves • Marfan syndrome


   Introduction
Top
 Summary
 Introduction
Surgical techniques
 Results
 Discussion
 References
 
Dystrophy represents the most common etiology of aortic insufficiency and aortic root aneurysms in Western countries [1]. Main characteristic lesions of dystrophic aortic roots are the constant dilation of the aortic annular base and sinotubular junction (STJ) diameters, preventing coaptation of otherwise pliable bicuspid or tricuspid valves (Table 1) [2]. Although these lesions are amenable to conservative aortic valve surgery, mechanical valve replacement remains the surgical standard [1, 3].


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  		Table 1 Anatomical lesions of dystrophic aortic roots

 
Two different valve sparing procedures have initially been described for aortic root aneurysms [4, 5]. The ‘remodeling’ technique (Yacoub et al.) reduces the sinotubular junction diameter and creates three neosinuses of Valsalva with a scalloped Dacron tube graft sutured in the supravalvular position [4]. Alternatively, David et al. proposed the ‘reimplantation’ of the aortic valve within a straight tube, reducing both the annulus and the sinotubular junction diameters to the detriment of cusp dynamics [5,6,7,8]. In order to treat the dilated diameters and to preserve the dynamic anatomy of the aortic root to ensure proper valve function, we suggest a standardized approach combining the advantages of both techniques by adding an external subvalvular prosthetic ring annuloplasty to the ‘remodeling’ (Table 2) (Schematic 1) [9,10,11,12].


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  		Table 2 Principles of conservative aortic valve surgery for aortic root aneurysms [4, 5, 9, 10]

 

Figure 1
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  		Schematic 1 Towards a technical standardization of conservative aortic valve surgery for aortic root aneurysm: remodeling technique (Yacoub et al., 1983 [4]); reimplantation technique (David et al., 1992 [5]); remodeling+subvalvular external aortic annuloplasty (Lansac et al., 2005 [9]).

 
The same principles are applied to standardize conservative valve surgery for isolated aortic insufficiency, by performing a double aortic annuloplasty with external sub- and supravalvular rings, in order to increase the level of coaptation and to protect the valve repair [11, 12] (Table 3) (Schematic 2).


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  		Table 3 Principles of conservative aortic valve surgery for isolated aortic insufficiency [11, 12]

 

Figure 2
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  		Schematic 2 Towards a technical standardization of conservative aortic valve surgery for isolated aortic insufficiency: sub- and supracommissural plicating stitches (Cabrol et al., 1966 [12]), Double sub- and supravalvular aortic annuloplasty (Lansac et al., 2005 [11]).

 
The proposed standardization of conservative aortic valve surgery relies on a systematic approach by:

  • transesophageal echocardiographic analysis of the regurgitant jet leading to define aortic insufficiency according to the anatomical lesions (Table 4). In case of a central jet, the lack of valvular coaptation is related to dilation of aortic root diameters (Type I). In case of an eccentric jet, the lack of valvular coaptation is related to the combination of a valvular lesion and the dilation of aortic root diameters (Type II). Each type of lesion corresponds to an adapted surgical strategy (Schematic 3).
  • intraoperative measurement of the internal aortic annular base diameter, as the sole criterion determining the choice of prosthetic ring and tube graft (Table 5).


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  		Table 4 Lesional classification of aortic insufficiency (bicuspid and tricuspid valves)
 

Figure 3
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  		Schematic 3 Surgical management strategy for aortic insufficiency based on the TEE analysis of the regurgitant jet.
 

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  		Table 5 Recommendations of use for various diameters of aortic prosthetic rings
 

   Surgical techniques
Top
 Summary
 Introduction
 Surgical techniques
Results
 Discussion
 References
 
Aortic root aneurysm with central aortic insufficiency: remodeling associated with a subvalvular aortic annuloplasty
Surgical management of an aortic root aneurysm with a central aortic insufficiency (or without aortic insufficiency) is based on a reduction of dilated diameters (subvalvular annuloplasty) and a physiological reconstruction of the aortic root (remodeling technique) (Schematic 4).


Figure 4
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  		Schematic 4 Remodeling associated with subvalvular external aortic annuloplasty.

 
1. Transesophageal echocardiographic evaluation of valvular insufficiency
The procedure is performed through a full median sternotomy. Mobilization of the aortic arch and ascending aorta are done, so that a high cannulation of the aortic arch can be performed, leaving place for the aortic cross-clamp close to the origin of the brachiocephalic trunk. Before going on cardiopulmonary bypass, the first step is transesophageal echocardiography (TEE), performed to measure the aortic root diameters and to identify the mechanisms of aortic insufficiency (Schematic 5, [13]). Particular attention is paid to the aspect of the leaflets (thin, pliable), direction of the regurgitant jet and identification of valve prolapse [central jet (Video 1) or eccentric jet (Video 2)]. Close collaboration between surgeon and echocardiographist is essential in order to define the plan for the surgical procedure.


Figure 5
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  		Schematic 5 Echocardiographic measurement of aortic root diameters (left) (12): (1) aortic annular base diameter (internal diameter), (2) sinuses of Valsalva (external diameter, comprising the aortic wall, from leading edge to leading edge), (3) sino-tubular junction (external diameter, comprising the aortic wall, from leading edge to leading edge), (4) ascending aorta (external diameter, comprising the aortic wall, from leading edge to leading edge). Right: transesophageal echocardiography of an aortic root aneurysm (Marfan syndrome) with dilated aortic annular base.

 

Figure 1
Click on image to view video		 Video 1 Preoperative transesophageal echocardiography of an aortic root aneurysm (long axis and short axis with color flow imaging sequences). Aortic insufficiency is grade III, with a central jet due to dilation of aortic root diameters (aortic annular base diameter: 26 mm, aneurysm diameter: 56 mm). Leaflets are thin and pliable.
 

Figure 2
Click on image to view video		 Video 2 Preoperative transesophageal echocardiography of an aortic root aneurysm with an eccentric grade III aortic insufficiency (long axis and short axis with color flow imaging sequences). The jet is directed towards the anterior mitral valve, related to prolapse of the right coronary cusp. The aortic annular base is dilated (27 mm), and the aneurysm is measured at 54 mm at its largest diameter. Leaflets are thin and pliable.
 
2. Inspection of the aortic valve
The heart is arrested with retrograde blood cardioplegia. Intermittent retrograde or antegrade cardioplegia is administered during the procedure. After aortic cross-clamping, the aneurysm is opened and the aortic root and valve are carefully inspected (particularly the geometry of the aortic valve and leaflet morphology). A thin and pliable valve is suitable for a valve-sparing procedure. The presence of a fenestration or a calcified nodule is not a contraindication.

3. Dissection of the aortic root and measurement of internal aortic annular base diameter
The aneurysm is totally removed. After resection of the sinuses of Valsalva within 2 mm of the aortic annulus, the subvalvular plane is dissected externally, below the nadir of insertion of each of the cusps (Video 3). Stay sutures are placed on the coronary buttons and commissures.


Figure 3
Click on image to view video		 Video 3 (Aorta on the top of the screen, right coronary ostia on the right). The wall of the aortic sinus is totally removed leaving a fringe of aortic wall of approximately 2 mm. Extensive external dissection is performed down to the base of the aortic annulus. The external aspect of the aortic wall is dissected free from the base of the pulmonary artery and from the roof of the left atrium, in order to reach the subvalvular plane. The internal aortic annular base diameter is measured with Hegar dilators.
 
Special attention is paid to the direct measurement of the diameter of the native aortic annular base with Hegar dilators, in order to determine the appropriate size of the prosthetic aortic ring and tube graft (Table 5).

4. Placement of five subvalvular stitches
Five threads of 2.0 coated polyester fiber, non pledgeted (Ethibond, Ethicon Inc., Somerville NJ, USA), are placed from the inside out as ‘U’ stitches (width of 3 mm) circumferentially in the subvalvular plane. Three stitches are placed 2 mm below the nadir of insertion of each cusp, and two stitches are placed below two of the three commissures at the base of the interleaflet triangles (no suture is placed at the base of the interleaflet triangle situated between the right and non-coronary sinuses to avoid injury to the bundle of His) (Video 4, Schematic 6).


Figure 4
Click on image to view video		 Video 4 (Aorta on the top of the screen, right coronary ostia on the right). A series of 5 ‘U’-stitches are passed in horizontal fashion below the valve taking care not to pinch the belly of the leaflets. Cusp is retracted with a grasper at the level of the nodule of Arantius, in order to allow placement of the stitch in the subvalvular plan. No suture is placed below the commissure between the non-coronary and right coronary sinus, in order to prevent injury to the bundle of His.
 

Figure 6
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  		Schematic 6 The order of placement of the subvalvular ‘U’ stitches start below the middle of the non-coronary cusp, turning clockwise up to the middle of the right coronary sinus.

 
5. Supravalvular replacement of the aortic root: the remodeling technique
The graft size is chosen according to Table 5, one millimeter below the subvalvular aortic ring diameter. The remodeling technique is performed as originally described by Yacoub, using a Gelweave ValsalvaTM graft (MMCTSLink 72) that has been tailored with three sinuses of Valsalva (Video 5). Three continuous 5.0 Prolene running sutures are performed, starting at the nadir of each sinus towards the adjacent commissure. Each half-running suture is knotted at the bottom of the sinus to ensure proper tension and hemostasis of the suture line. Root reconstruction starts at the left coronary sinus, followed by the non-coronary sinus, then the right coronary sinus (Photo 1, Video 6). Special care should be taken to resuspend the commissure in its proper position; in order to avoid distortion of the valve which in turn could induce a prolapse.


Figure 5
Click on image to view video		 Video 5 Collar of the Gelweave Valsalva graft is trimmed. The graft is tailored to fashion three neosinuses of Valsalva, oriented relative to the graft markers. The height of the neocommissure is set by the height of the graft skirt.
 

Figure 1
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  		Photo 1 Standardized suture of the graft for supravalvular replacement of the aortic root. Suture is knotted at the bottom of the sinus, and performed towards the adjacent commissure (curved arrow). Suture begins with left coronary sinus (1 and 2), followed by the non-coronary sinus (3 and 4) and ends with the right coronary sinus (5 and 6).

 

Figure 6
Click on image to view video		 Video 6 (Aorta on the top of the screen, right coronary ostia on the right). Standardized suturing of the graft for supravalvular replacement of the aortic root. Two of the neosinuses are rolled up into the graft, thereby exposing only the foliate to be sutured. The sewing direction is maintained in native tissue from the inside of the lumen outward in order to avoid the risk of leaflet puncture and to ensure accurate and consistent suture placement with respect to leaflets. Knots are then tied between adjacent sutures meeting at the commissure.
 
6. Placement of the aortic prosthetic ring in subvalvular position
The five anchoring ‘U’ stitches are passed through the inner aspect of the prosthetic expansible aortic ring (Extra aortic, CORONEO Inc., Montreal, QC, Canada) (Photo 2, Schematic 7). The ring is then descended into position, externally around the Gelweave graft and native aortic root, and tied in the subvalvular position (Video 7).


Figure 2
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  		Photo 2 Prosthetic expansible aortic ring (Extra aortic, CORONEO Inc., Montreal, QC, Canada). Black indicator marks on the ring, and suture windows in the ring-holder, are meant to guide suture placement.

 

Figure 7
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  		Schematic 7 The aortic annuloplasty ring is constructed from two elastic cores enclosed within a textile sheath (A). The ring is compliant to allow systolic expansion of its diameter. Correct (green) and incorrect (red) U-stitch suture placements are shown on part (B).

 

Figure 7
Click on image to view video		 Video 7 (Aorta on the top of the screen, right coronary ostia on the right). Placement of the prosthetic aortic ring in the subvalvular position: once the suturing of the tube graft to the native aortic root is complete, the five anchoring U-stitches are passed through the inner aspect of the expansible aortic ring. Black indicator marks on the ring, and suture windows in the ring-holder, are meant to guide suture placement. The attachment point between the handle and the ring-holder is aligned with the atrioventricular node. After all five of the U-stitches have been placed, the integrated ring-holder is pushed down at the subvalvular level over the tube graft. Surgical assistants maintain tension on the free ends of the U-stitches as the aortic ring is pushed into position. Once the ring is descended into position, the knots are tied, tightened and cut for all five positioning U-stitches. Tying and tightening the knots can be performed with the handle connected to the ring-holder or after it is detached by pressing the handle button to release the ball end out of the ring-holder slot. The retaining straps (3) are then cut to release the aortic ring from the holder, and the holder is removed from the implantation site.
 
7. Evaluation of valvular coaptation
At this point, valve leaflets are tested for the proper level of coaptation. If induced prolapse is observed, plicating stitches or running sutures are added to resuspend the free edge of the culprit leaflet.

8. Reimplantation of the coronary ostia buttons and distal anastomosis
Coronary ostia are then re-implanted into the neosinuses of the graft using 5.0 Prolene, starting with the left coronary button. Distal anastomosis is performed using a 4–5/0 Prolene running suture in a standard fashion (Video 8).


Figure 8
Click on image to view video		 Video 8 (Left coronary ostia on the left, aorta on the bottom of the screen). Reimplantation of the coronary ostia buttons into the ‘neosinuses’ of the Gelweave Valsalva graft and distal anastomosis between the tube graft and native distal aorta.
 
9. Transesophageal perioperative verification of valve repair
The patient is taken off cardiopulmonary support. Transesophageal echocardiography is performed to evaluate valvular function and competence when mean aortic pressure is above 70 mmHg. Any eccentric jet or aortic regurgitation (>grade 1) prompts further correction (Video 9 and Photo 3).


Figure 9
Click on image to view video		 Video 9 Perioperative control of Video 1 after performance of the remodeling technique associated with a subvalvular external aortic annuloplasty (long axis and short axis with color flow imaging sequences). Diameter of the prosthetic ring: 28 mm, postoperative aortic annulus diameter: 21 mm. Absence of residual aortic insufficiency.
 

Figure 3
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  		Photo 3 Postoperative CT scan (day 5) showing reconstruction of the aortic root using the ‘remodeling’ technique combined with a subvalvular aortic ring long axis (left), short axis (right) (with measure of the total aortic surface area).

 
Aortic root aneurysm with eccentric aortic insufficiency: remodeling associated with a subvalvular aortic annuloplasty and treatment of valvular lesion
In this case, the surgical steps are similar to the one described for a central aortic insufficiency, except for treatment of cusp lesion which is performed prior to remodeling of the aortic root, as detailed in Schematics 3 and 8.


Figure 8
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  		Schematic 8 Conservative aortic valve surgery: step by step.

 
The surgical technique is tailored to the specific valve lesion assessed on TEE and confirmed by sight, after the aorta is opened. The most common lesions are cusp prolapse and bicuspid valves.

1. Cusp prolapse
Valve analysis begins with examination of the length of the free margin of the leaflets. The prolapsing leaflet will be identified as the one with the longest and the lower free margin. Resuspension of the cusp is obtained either:

  • by plicating the central portion of the free edge with single stitches of 5-0 or 6-0 Prolene (Schematic 9); or
  • by a Goretex (MMCTSLink 128) reinforcement of the free edges of the leaflet, starting from the nodulus of Arantius and running up to both commissures (Schematic 10)


Figure 9
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  		Schematic 9 Plicating stitches of the central portion of the prolapsing cusp. A series of single stitches of 5-0 or 6-0 Prolene are passed on either side of the nodulus of Arantius.
 

Figure 10
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  		Schematic 10 Running suture on the free edge of the prolapsing cusp (using 5-0 or 6-0 Goretex). The suture is tied at the middle of the free edge (nodulus of Arantius). The running suture is stopped at the commissure, on the external side of the aortic wall on a Teflon pledget.
 
2. Bicuspid valves
Key points of bicuspid valves with a median raphe are:

  • Dissection of the aortic root and resection of the sinuses of Valsalva performed as described for tricuspid valve. At the level of the median raphe, a ‘third’ commissure is individualized (Video 10).
  • Treatment of valve prolapse is based on the resection of the median raphe. Repair of the cusp is performed with running suture of 5-0 or 6-0 Prolene (Videos 11 and 12 and Photo 4).
  • The ‘remodeling’ of the root is standardized using a Gelweave ValsalvaTM graft scalloped to form three neosinuses of Valsalva, as for a tricuspid valve (Video 13).


Figure 10
Click on image to view video		 Video 10 (Left coronary ostia on the left, aorta on the bottom of the screen). Bicuspid valve with median raphe (fusion of the left and right coronary cusp). The valve is predominantly prolapsing at the level of the right coronary cusp and of the median raphe. Aortic root aneurysm is resected preserving 3 commissures, which are tracted with stay sutures. Internal annular base diameter is measured with Hegar dilator.
 

Figure 11
Click on image to view video		 Video 11 (Left coronary ostia on the left, aorta on the bottom of the screen). Treatment of prolapsing fused left and right coronary cusp. The width of the triangular resection is adapted to the length of the free edge of the non-prolapsing cusp. After resection of the median raphe, stay sutures are placed on both sides of the hemi-cusps to facilitate the repair. A calcified nodule is removed from the left hemi-cusp.
 

Figure 12
Click on image to view video		 Video 12 (Left coronary ostia on the left, aorta on the bottom of the screen). Zoom on the management of a calcified median raphe. A ‘third’ commissure has been preserved at the level of the median raphe.
 

Figure 4
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  		Photo 4 Zoom on the treatment of a prolapsing median raphe of a bicuspid valve.
 

Figure 13
Click on image to view video		 Video 13 (Left coronary ostia on the left, aorta on the bottom of the screen). Remodeling of the aortic root with the Gelweave ValsalvaTM graft scalloped to create three neosinuses of Valsalva, for patient of Video 11 (bicuspid valve). Subvalvular external aortic annuloplasty reduces the annular size, increases the surface of coaptation in order to protect the repaired bicuspid valve.
 
In case of bicuspid valves without median raphe, the Valsalva graft is tailored into two symmetrical halves.

3. Isolated aortic insufficiency: double sub- and supravalvular external aortic annuloplasty
Surgical management of isolated dystrophic aortic insufficiency is based on the repair of valvular lesion, and the reduction of dilated diameters of the aortic root (sub- and supravalvular aortic annuloplasty). The procedure begins with a pre-operative transesophageal echocardiography to measure the aortic root diameters and evaluate valvular insufficiency (Video 14).


Figure 14
Click on image to view video		 Video 14 Preoperative TEE of an isolated dystrophic aortic insufficiency with an eccentric grade IV aortic insufficiency (long axis and short axis with color flow imaging sequences). The jet is directed towards the anterior mitral valve, related to prolapse of the right coronary cusp. The aortic annular base and sino-tubular junction diameters are dilated, 33 mm and 37 mm, respectively. Leaflets are thin and pliable.
 
4. Inspection of the aortic valve
After aortic cross-clamping, the aorta is completely transected and the aortic root and valve are carefully inspected [particularly the leaflet morphology and presence of cusp prolapse (Photo 5)].


Figure 5
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  		Photo 5 Case of isolated aortic insufficiency related to prolapse of the right coronary cusp. Treatment is performed by resuspension with a running Goretex suture.

 
5. Dissection of aortic annular base and measurement of internal aortic annulus diameter
External dissection down to the base of the aortic annulus is performed, passing under the coronary arteries, without detaching them from the aortic wall. The subvalvular plane is reached, 2 mm below the lowest point of insertion of each cusp (nadirs) (Video 15).


Figure 15
Click on image to view video		 Video 15 (Left coronary ostia on the left, aorta on the bottom of the screen). After complete transection of the aorta, extensive dissection of the root is performed without detaching the coronary buttons. The external aspect of the aortic wall is dissected free from the base of the pulmonary artery and from the roof of the left atrium, in order to reach the subvalvular plane. The internal aortic annular base diameter is measured with Hegar dilators.
 
Special attention is paid to the direct measurement of the diameter of the native aortic annular base with Hegar dilators, in order to determine the appropriate size of the sub- and supravalvular prosthetic rings (Table 5).

6. Placement of sub- and supravalvular stitches
Five threads of 2.0 coated polyester fiber, non-pledgeted (MMCTSLink 24 – Ethibond), are placed from the inside out as ‘U’ stitches (width of 3 mm) circumferentially in the subvalvular plane. Three stitches are placed 2 mm below the nadir of insertion of each cusp, and two stitches are placed below two of the three commissures at the base of the interleaflet triangles (no suture is placed at the base of the interleaflet triangle situated between the right and non-coronary sinuses to avoid injury to the bundle of His). Three ‘U’ stitches of 2.0 coated polyester fiber, non-pledgeted, are passed at the level of each commissure (Video 16).


Figure 16
Click on image to view video		 Video 16 (Left coronary ostia on the left, aorta on the bottom of the screen). The three sutures of the supravalvular ring are placed as stay sutures on each of the commissures. They will later be used to anchor the supravalvular ring. A series of 5 ‘U’-stitches are passed in horizontal fashion below the valve taking care not to pinch the belly of the leaflets. Cusp is retracted with a grasper at the level of the nodule of Arantius, in order to allow placement of the stitch in the subvalvular plane. No suture is placed below the commissure between the non-coronary and right coronary sinus, in order to prevent injury to the bundle of His.
 
7. Treatment of associated valvular lesion
Treatment of valvular lesion is then performed, adapted to echocardiographic and surgical perioperative findings. The free edge of the prolapsed valve is resuspended with plicating stitches or a running suture (Photo 5, Video 17).


Figure 17
Click on image to view video		 Video 17 (Left coronary ostia on the left, aorta on the bottom of the screen). Resuspension of the free edge of the prolapsing cusp with running suture using 5-0 or 6-0 Goretex. A fenestration is closed with the running suture. The suture is tied at the middle of the free edge (nodulus of Arantius). The running suture is stopped at the commissure, on the external side of the aortic wall on a Teflon pledget.
 
8. Placement of the subvalvular aortic prosthetic ring
Once adequate coaptation is confirmed, the subvalvular stitches are passed through the inner aspect of the ‘open’ subvalvular prosthetic ring, in order that it may be positioned below the coronary arteries without having to detach them from the aortic root (Video 18).


Figure 18
Click on image to view video		 Video 18 (Left coronary ostia on the left, aorta on the bottom of the screen). Placement of the prosthetic aortic ring in the subvalvular position, under the coronary arteries. The ring is closed with a series of ‘U’ stitches. Aortotomy is closed in a standard fashion and the second ring is tied and closed in the supravalvular position.
 
9. Supravalvular aortic annuloplasty
The aortotomy is closed in standard fashion with running suture (5-0 or 4-0 Prolene). The commissural stitches are then passed through the inner aspect of a supravalvular aortic ring and tied at the level of the sinotubular junction (Video 18).

10. Transesophageal perioperative verification of valve repair
The patient is taken off cardiopulmonary support. Transesophageal echocardiography is performed to evaluate valvular function and competence when mean aortic pressure is above 70 mmHg. Any eccentric jet or aortic regurgitation (>grade 1) prompts further correction (Video 19).


Figure 19
Click on image to view video		 Video 19 Peri-operative control of Video 14 after performance of a double sub- and supravalvular external aortic annuloplasty (diameter of the subvalvular prosthetic ring: 30 mm, diameter of the supravalvular prosthetic ring: 30 mm, postoperative aortic annulus diameter: 22 mm). Surface of valvular coaptation is increased, without residual aortic insufficiency.
 

   Results
Top
 Summary
 Introduction
 Surgical techniques
 Results
Discussion
 References
 
Since May 2003, this standardized procedure was conducted in 68 patients with dystrophic aortic roots (59 patients with aortic root aneurysms, 9 patients with isolated aortic insufficiency) [9,10,11].

Preoperative aortic annulus and STJ diameters were dilated in all cases, and significantly reduced after the annuloplasty, without a significant mean systolic gradient (6.5±1.4 mmHg) (Table 6). Concomitant cusp repair was performed in 15 cases of associated eccentric aortic regurgitant jet. Two patients required perioperative conversion (2.9%). The degree of aortic insufficiency, size of aortic root aneurysm, presence of Marfan syndrome (16 patients, 27.1% of all aortic root aneurysms) or bicuspid valves (8 patients, 13.6% of all aortic root aneurysms) had no effect on the risk of requiring conversion. Operative morbidity and mortality are summarized in Table 6. Three patients (5%) in the aortic root aneurysm group died in the early postoperative period (one due to massive pulmonary embolism, one due to mesenteric ischemia, one for unknown reason). An atrioventricular block requiring pacemaker implantation was observed in three patients from the aortic root aneurysm group. The first two cases were at the beginning of our experience with the subvalvular annuloplasty, and this led us to remove a 6th ring-anchoring stitch above the commissure between the non-coronary and right coronary sinuses of Valsalva, in order to avoid potential injury to the bundle of His. Since this change in technique no atrioventricular block was observed, except for one case of a bicuspid valve where 6 anchoring stitches had to be used.


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  		Table 6 Preliminary results of aortic annuloplasty to treat dystrophic aortic roots

 
One patient presented a cardiopulmonary arrest related to a transient atrioventricular block. One patient was reoperated for a mediastinitis, and two patients suffered from a transient ischemic attack (patent foramen ovale in one case). No complications or reoperations occurred in the double annuloplasty group.

Two patients with aortic root aneurysm required re-operation for significant aortic regurgitation, respectively 3 and 5 months after their initial surgery. In both cases, an eccentric grade I+ aortic regurgitation was present at the first intraoperative TEE, and was related to residual cusp prolapse which was neglected. At reoperation, cusp prolapse was confirmed as the cause of valve failure. Valve replacement was performed via a usual ‘aortotomy’ on the Dacron tube graft using standard technique for implantation of a mechanical valve (Schematic 11). Both patients recovered promptly from the second operation. No late deaths, bleeding, thromboembolic, or endocarditis events were reported in either group during follow-up (respectively 20 months (3–37) for aortic root aneurysms and 21 months (8–38) for isolated dystrophic aortic insufficiencies).


Figure 11
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  		Schematic 11 Technique for conversion to a valve replacement in case of failure of a conservative aortic valve surgery.

 

   Discussion
Top
 Summary
 Introduction
 Surgical techniques
 Results
 Discussion
References
 
The aortic valve is a three-dimensional complex, with a sigmoid shaped annulus, related to the semi-lunar attachments of its leaflets [14, 15]. This structure can be divided in two circular components: the base of the aortic annulus and the STJ, which when dilated define the characteristic lesions of dystrophic aortic roots [2]. The main goal of external aortic annuloplasty is to increase valve coaptation by the reduction of the aortic annulus and STJ diameters, in order to protect the valve repair. These principles are known since the early 1960s, as initially described by Cabrol et al., who performed plicating sutures at the base of the interleaflet triangles [12].

This standardized approach of conservative aortic valve surgery with external aortic annuloplasty was performed in four different institutions by 13 different surgeons, thus confirming its reproducibility. Although original series provides excellent results at 5–10 years follow-up, with a low rate of valve related complications or thromboembolic events, it remains unknown whether a valve-sparing procedure provides better long-term results than a prosthetic valve replacement (Table 7, [16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42]). Objective and long-term evaluation is needed to pursue evidence-based medical data. A prospective, multi-center randomized open trial, the CAVIAAR study (conservative aortic valve surgery for aortic insufficiency and aneurysm of the aortic root), will be enrolling patients over the next 3 years, comparing 100 patients with this standardized valve-sparing procedure to 100 patients with mechanical valve replacement. Thirty French cardiac surgery centers will be participating. Standardization and rigorous clinical evaluation should allow us to objectively define the optimum surgical strategy for patients with dystrophic aortic roots.


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  		Table 7 Results of a recent series of valve sparing operations, compared with composite graft replacement

 


   Footnotes
 
1 Two of the authors have Consultant Agreements with the company CORONEO Inc., in connection with the development of an aortic ring bearing the trade name ‘Extra Aortic’. Back

2 Dr Lansac is the inventor of the aortic ring, whose patent rights have been assigned to the Assistance Publique Hôpitaux de Paris (APHP). The APHP has licensed the patent rights for this aortic ring to CORONEO under a Development and License Agreement. Back

3 The study received outside financial support for the recordings of the videos, by the Fédération Française de Cardiologie (FFC) and the Association Chirurgicale pour le Développement et l'Amélioration des Techniques de Dépistage et de Traitement des Maladies Cardio-vasculaires (Adetec). Back


   References
Top
 Summary
 Introduction
 Surgical techniques
 Results
 Discussion
 References
 

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